LCD Reference Article Billing and Coding Article

Billing and Coding: Implantable Automatic Defibrillators

A56326

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Source Article ID
N/A
Article ID
A56326
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Implantable Automatic Defibrillators
Article Type
Billing and Coding
Original Effective Date
03/26/2019
Revision Effective Date
03/03/2023
Revision Ending Date
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Retirement Date
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CMS National Coverage Policy

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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, 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-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 40 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 40 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 

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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. Procedure code 02PAXMZ is no longer valid after 10/01/2021.

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. Effective 01/01/2023 the billing and coding guidelines apply to the following HCPCS codes: C7537, C7538, C7539 and C7540.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(45 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
Code Description
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
I5A Non-ischemic myocardial injury (non-traumatic)
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
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

(30 Codes)
Group 1 Paragraph

The following ICD-10 PCS Codes include both the Part A insertion and removal codes.

Group 1 Codes
Code Description
02H43KZ Insertion of Defibrillator Lead into Coronary Vein, Percutaneous Approach
02H60KZ Insertion of Defibrillator Lead into Right Atrium, Open Approach
02H63KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach
02H64KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Approach
02H70KZ Insertion of Defibrillator Lead into Left Atrium, Open Approach
02H73KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Approach
02H74KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Approach
02HK0KZ Insertion of Defibrillator Lead into Right Ventricle, Open Approach
02HK3KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach
02HK4KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic Approach
02HL0KZ Insertion of Defibrillator Lead into Left Ventricle, Open Approach
02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach
02HL4KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Approach
02PA0MZ Removal of Cardiac Lead from Heart, Open Approach
02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous Approach
02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic Approach
0JH608Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH609Z Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH60FZ Insertion of Subcutaneous Defibrillator Lead into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH638Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH639Z Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH63FZ Insertion of Subcutaneous Defibrillator Lead into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH808Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH809Z Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH838Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH839Z Insertion of Cardiac Resynchronization Defibrillator Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
0JPT0FZ Removal of Subcutaneous Defibrillator Lead from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3FZ Removal of Subcutaneous Defibrillator Lead from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
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Additional ICD-10 Information

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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.

Code Description

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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.

Code Description

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Other Coding Information

Group 1

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
03/03/2023 R6

Based on Transmittal 11832 (CR13070) International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)—July 2023 Update, HCPCS codes C7537, C7538, C7539 and C7540 have been added effective for dates of service on or after 01/01/2023.

10/01/2022 R5

Based on Transmittal 11676 (CR 12960) International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs) — April 2023 Update, ICD-10 code I47.20 has been added to the Group 1 codes. ICD-10 code I47.20 has been added to the following sentence under Item B1 in the Article Text section: 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, I5A, Z45.02 or Z86.74.

10/01/2022 R4

Based on Transmittal 11440 (CR 12705)–Annual (2023) Update of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), ICD-10 code I47.2 has been deleted from the Group 1 codes and ICD-10 codes I47.21 and I47.29 have been added. ICD-10 code I47.2 has been removed and ICD-10 codes I47.21 and I47.29 have been added to the following sentence under Item B1 in the Article Text section: ICD-10-CM codes which describe the above: I46.2, I46.9, I47.21, I47.29, I49.01, I49.02, I49.3, I49.9, I5A, Z45.02 or Z86.74.

11/23/2021 R3

Added the ICD-10-PCS insertion and removal codes in the ICD-10-PCS Codes Section. Based on Transmittal 11068, Change Request 12480 - International Classification of Diseases April 2022, ICD-10 code I5A has been added to the Group 1 codes effective 10/01/2021.

05/07/2020 R2

This article was converted to the new Billing and Coding Article format.

10/01/2019 R1

Based on Transmittal 4324 (CR 11333 - Fiscal Year (FY) 2020 Annual Update to the Medicare Code Editor (MCE) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS), ICD-10-PCS codes 0JH60FZ, 0JH63FZ, 0JPT0FZ and 0JPT3FZ have been added to item “D. Other” section of the article effective for dates of service on or after 10/01/2019.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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