Permanent Cardiac Pacemaker Implant

Affected Providers

Physicians and facilities who bill for cardiac pacemaker implants.

HCPCS & CPT Codes

Article: Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers has the current HCPCS and CPT codes. Select your Medicare Administrative Contractor’s (MAC’s) article from the search results.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for permanent cardiac pacemaker implants is 2.4%, with a projected improper payment amount of $20.2 million.

Permanent cardiac pacemakers are a group of self-contained, battery-operated, implanted devices that send electrical stimulation to the heart through 1 or more implanted leads.

They’re often classified by the number of heart chambers the devices stimulate (pulse or depolarize). Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle.

You must meet provisions in National Coverage Determination (NCD): Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3).

Preventing Denials

Nationally Covered Indications

We cover implanted permanent single chamber or dual chamber cardiac pacemakers for documented non-reversible symptomatic bradycardia due to either:

• Sinus node dysfunction
• Second-degree or third-degree atrioventricular block

Nationally Non-Covered Indications:

We don’t cover implanted permanent single chamber or dual chamber cardiac pacemakers for:

• Reversible causes of bradycardia, like electrolyte abnormalities, medications or drugs, and hypothermia
• Asymptomatic first-degree atrioventricular block
• Asymptomatic sinus bradycardia
• Asymptomatic sino-atrial block or asymptomatic sinus arrest
• Ineffective atrial contractions (for example, chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia
• Asymptomatic second-degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have shown the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart)
• Syncope of undetermined cause
• Bradycardia during sleep
• Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block
• Asymptomatic bradycardia in post-myocardial infarction patients about to start long-term beta-blocker drug therapy
• Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia
• A clinical condition in which pacing takes place only intermittently and briefly and is not associated with a reasonable likelihood that pacing needs will become prolonged

A surgical provider submits the following plan of care documentation per the review contractor’s request:

• Patient’s history and medical records with a diagnosis of asymptomatic sinus bradycardia
• Surgical records

What Documentation Was Missing?

The medical record didn’t include a nationally covered indication for a permanent cardiac pacemaker implant.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the MAC recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation when billing for permanent cardiac pacemaker implants.