Local Coverage Article Billing and Coding

Billing and Coding: Cardiac Resynchronization Therapy (CRT)

A58821

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Contractor Information

Article Information

General Information

Article ID
A58821
Article Title
Billing and Coding: Cardiac Resynchronization Therapy (CRT)
Article Type
Billing and Coding
Original Effective Date
12/12/2021
Revision Effective Date
04/11/2022
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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CMS National Coverage Policy

All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations, and rules for Medicare payment for Biventricular Pacing/CRT and must properly submit only valid claims for them.

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §60.4 Noncovered Charges on Outpatient Bills

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §10.2.2 Cardiac Resynchronization Therapy

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §20.9 National Correct Coding Initiative (NCCI)

CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, §6.5.2 Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Resynchronization Therapy (CRT) L39080.

Services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules. Refer to the related LCD for reasonable and necessary requirements and limitations.

It is well-established that indications for CRT are based upon left ventricle (LV) ejection fraction (EF), QRS duration, QRS morphology, New York Heart Association (NYHA) functional class, and the need for ventricular pacing, if applicable. Therefore, it is important that all these attributes be documented within the patient’s medical record. Documentation detailing the risk-benefit equation for any given patient must be clear. Each patient has specific characteristics such as age, heart failure (HF) impact on quality of life, personal preferences, or a left/right predominance to a non-left bundle branch block (LBBB) scenario, etc. that may play a role in choice of treatment. Such unique issues should be documented.

Medical record documentation should also reflect a beneficiary who is on a stable pharmacologic regimen for HF before CRT implantation. This regimen may include any of the following, unless contraindicated: angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, beta blocker, digoxin, or diuretics.

The implanted CRT device must be United States Food and Drug Administration (FDA) approved for the CRT indication.

Necessary documentation elements for a patient in whom CRT implantation is planned:

  • Most recent EF measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiography
  • QRS duration in milliseconds (ms)
  • QRS morphology such as LBBB, non-LBBB (with additional clarifying comments as applicable), right bundle branch block (RBBB)
  • If present, any markedly prolonged first degree atrioventricular (AV) block or second- or third-degree AV block
  • Any plan for AV nodal ablation
  • NYHA class and any trends up or down within that classification
  • Frequent hospitalizations or office visits for acute exacerbations of HF - if occurring
  • Complete operative report outlining operative approach used and all the components of the biventricular pacemaker insertion
  • If applicable, the need for a pacemaker and an expectation that pacing is likely to occur much of the time

All documentation must be maintained in the patient's medical record and made available to the A/B MAC upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code(s) must describe the service performed. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient’s records and claims history.

For an upgrade from standard pacing to CRT, this A/B MAC would expect documentation narrative regarding the risk-benefit balance for that individual patient and his/her degree of HF, QRS duration/morphology, etc. A "stand-alone" upgrade in patients with an existing pacemaker or implanted cardiac defibrillator should be considered carefully and based on the individual patient’s unique circumstances.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the related LCD.

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

The following CPT® codes associated with CRT services may have diagnosis code limitations based on the related LCD

Group 1 Codes
CodeDescription
33224 INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, WITH ATTACHMENT TO PREVIOUSLY PLACED PACEMAKER OR IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR (INCLUDING REVISION OF POCKET, REMOVAL, INSERTION, AND/OR REPLACEMENT OF EXISTING GENERATOR)
33225 INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF INSERTION OF IMPLANTABLE DEFIBRILLATOR OR PACEMAKER PULSE GENERATOR (EG, FOR UPGRADE TO DUAL CHAMBER SYSTEM) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

Modifier - KX must be used as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the patient has sufficiently symptomatic HF and electrocardiographic evidence of dyssynchrony or sufficiently symptomatic HF with an EF < 50% and a need for frequent RV pacing.

For medically necessary CRT in conditions not addressed by this article, use modifier - SC.

Modifier – GA should be used when the provider wants to indicate that he/she anticipates that Medicare will deny a specific service as not reasonable and necessary, an Advanced Beneficiary Notice (ABN) Form CMS-R-131 has been signed by the beneficiary and is on file. Modifier – GA 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 are required.

Modifier – GZ should be used when the provider wants to indicate that it is expected that Medicare will deny the specific services as not reasonable and necessary and the beneficiary was not asked to sign an ABN.

Claims for pacemaker claims that do not meet the criteria for modifier – KX or – SC should have modifier – GA or – GZ appended depending on the ABN status and will be denied.

Group 1 Codes
CodeDescription
GA WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUAL CASE
GZ ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET
SC MEDICALLY NECESSARY SERVICE OR SUPPLY

ICD-10-CM Codes that Support Medical Necessity

Group 1

(7 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

One of the following Group 1 codes must be present on a CRT claim as a principal or secondary ICD-10 diagnosis code AND one of the Group 2 codes must be present on a CRT claim as a principal or secondary ICD-10 diagnosis code.

Group 1 Codes
CodeDescription
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

Group 2

(8 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

One of the following Group 2 codes must be present on a CRT claim as a principal or secondary ICD-10 diagnosis code AND one of the Group 1 codes must be present on a CRT claim as a principal or secondary ICD-10 diagnosis code.

Group 2 Codes
CodeDescription
I44.0 Atrioventricular block, first degree
I44.1 Atrioventricular block, second degree
I44.2 Atrioventricular block, complete
I44.7 Left bundle-branch block, unspecified
I45.10 Unspecified right bundle-branch block
I45.19 Other right bundle-branch block
I45.2 Bifascicular block
I45.3 Trifascicular block

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

N/A

ICD-10-PCS Codes

Group 1

(8 Codes)
Group 1 Paragraph

The following ICD-10-PCS codes associated with CRT services may have diagnosis code limitations based on the related LCD

Group 1 Codes
CodeDescription
02H43JZ Insertion of Pacemaker Lead into Coronary Vein, Percutaneous Approach
02H44JZ Insertion of Pacemaker Lead into Coronary Vein, Percutaneous Endoscopic Approach
02HL0JZ Insertion of Pacemaker Lead into Left Ventricle, Open Approach
02HL3JZ Insertion of Pacemaker Lead into Left Ventricle, Percutaneous Approach
0JH607Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH637Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH807Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH837Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach

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

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
04/11/2022 R1

Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes deleted I50.82. Under ICD-10-CM Codes that Support Medical Necessity Group 2: Codes deleted I44.4, I44.5, I44.69 and I45.0.

Associated Documents

Related Local Coverage Documents
LCDs
L39080 - Cardiac Resynchronization Therapy (CRT)
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
03/09/2022 04/11/2022 - N/A Currently in Effect You are here
10/19/2021 12/12/2021 - 04/10/2022 Superseded View

Keywords

  • Cardiac Resynchronization Therapy
  • CRT