SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based

A57038

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57038
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Surveillance of Implantable or Wearable Cardioverter Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based
Article Type
Billing and Coding
Original Effective Date
09/26/2019
Revision Effective Date
09/07/2023
Revision Ending Date
11/15/2023
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Section 1862 (a)(7) excludes routine physical examinations, unless otherwise covered by statute.

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34087.

 

General Guidelines for Claims submitted to Part A or Part B MAC:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

 

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

 

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.

 

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

 

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

An Internet based service may require a signed service agreement between the manufacturer and the physician. This agreement should be kept on file and be available upon request.

When the technical portion of interrogation services are provided by a service center (IDTF, hospital based laboratory, etc), or physician other than the one analyzing and interpreting the results (93296), the physician performing the review, analysis and report must generate his/her own interpretation and report (with signature) and not just countersign the technical review and distribution of results.

All of the following must be maintained in the patient’s medical record in the physician’s office: date(s) of device implant and identification of device, a copy of the physician’s order for the service, all transmissions, formal interpretations, reports, information relating the reason for the service: routine follow-up versus specific symptoms. If the reason for the service is that the patient was symptomatic, then the nature of the symptoms must be documented.


Not applicable

The frequency and need for both face-to-face and web-based modalities should be coordinated so that there are no unnecessary duplications of the interrogation services.

When the in-person service is rendered for monitoring purposes only, in the absence of symptoms or discharge of the device (ICD-10-CM code Z95.810), it is expected that the service be performed no more frequently than once every three months. Remote interrogation services may be billed no more often than once every 90 calendar days.

When the in-person service is rendered for other indications, it may be performed as appropriate based on clinical symptomatology.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0480 Cardiology - General Classification
0489 Cardiology - Other Cardiology
N/A

CPT/HCPCS Codes

Group 1

(8 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
93282 PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; SINGLE LEAD TRANSVENOUS IMPLANTABLE DEFIBRILLATOR SYSTEM
93283 PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; DUAL LEAD TRANSVENOUS IMPLANTABLE DEFIBRILLATOR SYSTEM
93284 PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; MULTIPLE LEAD TRANSVENOUS IMPLANTABLE DEFIBRILLATOR SYSTEM
93287 PERI-PROCEDURAL DEVICE EVALUATION (IN PERSON) AND PROGRAMMING OF DEVICE SYSTEM PARAMETERS BEFORE OR AFTER A SURGERY, PROCEDURE, OR TEST WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; SINGLE, DUAL, OR MULTIPLE LEAD IMPLANTABLE DEFIBRILLATOR SYSTEM
93289 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; SINGLE, DUAL, OR MULTIPLE LEAD TRANSVENOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, INCLUDING ANALYSIS OF HEART RHYTHM DERIVED DATA ELEMENTS
93292 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; WEARABLE DEFIBRILLATOR SYSTEM
93295 INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD IMPLANTABLE DEFIBRILLATOR SYSTEM WITH INTERIM ANALYSIS, REVIEW(S) AND REPORT(S) BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL
93296 INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, LEADLESS PACEMAKER SYSTEM, OR IMPLANTABLE DEFIBRILLATOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(33 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

Group 1 Codes
Code Description
I46.2 Cardiac arrest due to underlying cardiac condition
I46.8 Cardiac arrest due to other underlying condition
I47.0 Re-entry ventricular arrhythmia
I47.21 Torsades de pointes
I47.29 Other ventricular tachycardia
I47.9 Paroxysmal tachycardia, unspecified
I49.01 Ventricular fibrillation
I49.02 Ventricular flutter
R00.0 Tachycardia, unspecified
R00.2 Palpitations
R42 Dizziness and giddiness
R55 Syncope and collapse
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
T82.120A 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
T82.190A 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
T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.827A Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.837A Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.847A Pain due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.857A Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter
T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter
Z45.010* Encounter for checking and testing of cardiac pacemaker pulse generator [battery]
Z45.018* Encounter for adjustment and management of other part of cardiac pacemaker
Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator
Z95.0* Presence of cardiac pacemaker
Z95.810 Presence of automatic (implantable) cardiac defibrillator
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation


*ICD-10 codes Z95.0, Z45.010, and Z45.018 are payable only for CPT code 93296. These ICD-10 codes have been added to this list only because CPT code 93296 refers to pacemaker systems in addition to implantable cardiac defibrillator systems in its descriptor. When this CPT code is reported for services for implantable or wearable cardioverter defibrillators, coverage defined in this LCD applies.

N/A

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

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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.

Code Description
011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
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.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.


Code Description
0480 Cardiology - General Classification
0489 Cardiology - Other Cardiology
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation
09/07/2023 R6

R6

Revision Effective: 09/07/2023

Revision Explanation: Annual review, no changes. 

10/01/2022 R5

R5

Revision Effective: 10/01/2022

Revision Explanation: Annual ICD-10 Update,  Removed I47.2 and added I47.21 and I47.29  

09/01/2022 R4

R4

Revision Effective: 09/01/2022

Revision Explanation: Annual review, no changes were made.

08/19/2021 R3

R3

Revision Effective: 08/19/2021

Revision Explanation: Annual review, no changes were made.

06/03/2021 R2

R2

Revision Effective: 01/01/2021

REvison Explanation: Codes Z48.03 and Z48.89 were removed from group 1 ICD-10 as they were listed in error. Asterisk was removed from codes Z45.02,T852.110A, T82.118A, T82.120A, T82.121A, T82.128A, T82.190A, T82.191A, and T82.198A.

08/25/2020 R1

Revision Effective: n/a

Revision Explanation: Annual review, no changes made

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
11/07/2023 11/16/2023 - N/A Currently in Effect View
08/31/2023 09/07/2023 - 11/15/2023 Superseded You are here
09/21/2022 10/01/2022 - 09/06/2023 Superseded View
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Keywords

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