Cardiac Pacemakers 2014 HOSPITAL REIMBURSEMENT GUIDE

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Contents Page Introduction 03 Medicare Coding and Payment Overview

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Hospital Inpatient

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Hospital Outpatient

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HCPCS Device Category C-Codes

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Coverage for Pacemaker Procedures

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References 07

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Introduction This guide provides hospital coding and payment information for pacemaker procedures. In addition, St. Jude Medical offers a reimbursement hotline, which provides live coding and billing information from dedicated reimbursement specialists. Hotline support is available from 8:00 a.m. to 5:00 p.m. Central Time, Monday through Friday at (855) 569-6430. This document and the information contained herein is for general information purposes only and is not intended and does not constitute legal, reimbursement, coding, business or other advice. Furthermore, it is not intended to increase or maximize payment by any payer. Nothing in this document should be construed as a guarantee by St. Jude Medical regarding levels of reimbursement, payment or charge, or that reimbursement or other payment will be received. Similarly, nothing in this document should be viewed as instructions for selecting any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third party payers. Also note that the information presented herein represents only one of many potential scenarios, based on the assumptions, variables and data presented. In addition, the customer should note that laws, regulations and coverage and coding policies are complex and are updated frequently, and therefore the customer should check with its local carriers or intermediaries often and should consult with legal counsel or a financial, coding or reimbursement specialist for any coding, reimbursement or billing questions or any related issues. Please check the user’s manual for the FDA approved indications for use.

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Medicare Coding and Payment Overview Hospital Inpatient Possible ICD-9-CM Codes

Effective Dates: October 1, 2013 – September 30, 2014 MS-DRG

Description

Medicare National Average MS-DRG Payment

Pacemaker System Implant 37.71 37.72 37.73 37.76 37.80 37.81 37.82 37.83 37.85 37.86 37.87 00.50

244

Permanent cardiac pacemaker implant without CC/MCC

$12,532

243

Permanent cardiac pacemaker implant with CC

$15,494

242

Permanent cardiac pacemaker implant with MCC

$21,743

259

Cardiac pacemaker replacement without MCC

$11,287

258

Cardiac pacemaker replacement without MCC with MCC

$15,792

262

Cardiac pacemaker revision except device replacement without CC/MCC

$8,042

261

Cardiac pacemaker revision except device replacement with CC

$10,024

260

Cardiac pacemaker revision except device replacement with MCC

$21,597

Pacemaker Generator Replacement 37.80 37.81 37.82 37.83 37.85 37.86 37.87 00.53 Pacemaker Revision 37.75 37.76 37.77 37.79 37.80 37.85 37.86 37.87 37.89 37.98 00.53

CC – complications and comorbidities; MCC – major complications and comorbidities

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Hospital Outpatient CPT Code

Effective Dates: January 1, 2014 – December 31, 2014 Description

APC

APC Description

SI

Average APC Payment

Pacemaker System Implant 33206

Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial

33207

ventricular

0089

Insertion/Replacement of Permanent Pacemaker and Electrodes

T

$8,790*

0655

Insertion/Replacement/Conversion of a Permanent Pacemaker, Dual Chamber Pacemaker or Pacing Electrode (includes LV lead)

T

$10,588*

0090

Level I Insertion/Replacement of Permanent Pacemaker (Single chamber)

T

$7,353*

0654

Level II Insertion/Replacement of Permanent Pacemaker (Dual and multiple chamber)

T

$8,388*

0106

Insertion/Replacement/Repair of Pacemaker Generator, Leads, and/or Electrodes

T

$4,602*

0655

Insertion/Replacement/Conversion of a Permanent Pacemaker, Dual Chamber Pacemaker or Pacing Electrode (includes LV lead)

T

$10,588*

0105

Repair/Revision/Removal of Pacemakers, ICDs, Vascular Devices (includes repositioning of LV lead)

T

$2,318*

0328

Level III Skin Repair (relocation of skin pocket for pacemaker or ICD)

T

$1,371*

33214

Upgrade of pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator)

0655

Insertion/Replacement/Conversion of a Permanent Pacemaker, Dual Chamber Pacemaker or Pacing Electrode (includes LV lead)

T

$10,588*

33227

Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system

0090

Level I Insertion/Replacement of Permanent Pacemaker (Single chamber)

T

$7,353*

0654

Level II Insertion/Replacement of Permanent Pacemaker (Dual and multiple chamber)

T

$8,388*

0105

Repair/Revision/Removal of Pacemakers, ICDs, Vascular Devices (includes repositioning of LV lead)

T

$2,318*

33208

atrial and ventricular

Pacemaker Generator Implant 33212

33213 33221

Insertion of pacemaker pulse generator only; with existing single lead

with existing dual leads with existing multiple leads

Insertion of Lead(s) 33216 33217

Insertion of a single lead Insertion of two leads

+33224

Insertion of LV lead, with attachment to previously placed pacemaker or ICD generator (including revision of pocket, removal, insertion and/ or replacement of existing generator)

+33225

Insertion of LV lead at time of insertion of pacemaker or ICD generator (including upgrade to dual chamber system and pocket revision)

Repositioning/Repair/Revision 33215

Repositioning of previously implanted transvenous pacemaker or ICD lead (right atrial or right ventricular)

33226

Repositioning of previously implanted LV lead (including removal, insertion and/or replacement of existing generator)

33218

Repair of single lead

33222

Relocation of skin pocket for pacemaker

Removal and/or Replacement

33228 33229

dual lead system multiple lead system

33233

Removal of pacemaker generator, without replacement

33234

Removal of pacemaker lead(s); single lead system

33235

dual lead system

Status Indicators: S=Significant Procedure, Not discounted for multiple procedures; T = Significant procedure, not discounted when multiple; X = Ancillary services *Note: Payment for this APC may change on a quarterly basis. Please consult www.cms.gov.

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ICD 10 Table for EP Procedures ICD-9 v3

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ICD-10 PCS Equivalent Codes*

37.71 - Initial insertion of transvenous lead [electrode] into ventricle

02HK3JZ - Insertion of Pacemaker Lead into R Ventricle, Perc Approach 02HK3MZ - Insertion of Cardiac Lead into R Ventricle, Perc Approach 02HL3JZ - Insertion of Pacemaker Lead into L Ventricle, Perc Approach 02HL3MZ - Insertion of Cardiac Lead into Left Ventricle, Perc Approach

37.72 - Initial insertion of transvenous leads [electrodes] into atrium and ventricle

02H63JZ - Insertion of Pacemaker Lead into Right Atrium, Perc Approach 02H73JZ - Insertion of Pacemaker Lead into Left Atrium, Perc Approach 02HK3JZ - Insertion of Pacemaker Lead into R Ventricle, Perc Approach 02HL3JZ - Insertion of Pacemaker Lead into L Ventricle, Perc Approach

37.73 - Initial insertion of transvenous lead [electrode] into atrium

02H63JZ - Insertion of Pacemaker Lead into Right Atrium, Perc Approach 02H73JZ - Insertion of Pacemaker Lead into Left Atrium, Perc Approach

37.76 - Replacement of transvenous atrial and/or ventricular lead(s) [electrode]

02H63JZ - Insertion of Pacemaker Lead into Right Atrium, Perc Approach 02H63JZ - Insertion of Pacemaker Lead into Right Atrium, Perc Approach 02H63MZ - Insertion of Cardiac Lead into Right Atrium, Perc Approach 02H73JZ - Insertion of Pacemaker Lead into Left Atrium, Perc Approach 02H73JZ - Insertion of Pacemaker Lead into Left Atrium, Perc Approach 02H73MZ - Insertion of Cardiac Lead into Left Atrium, Perc Approach 02HK3JZ - Insertion of Pacemaker Lead into R Ventricle, Perc Approach 02HK3JZ - Insertion of Pacemaker Lead into R Ventricle, Perc Approach 02HK3MZ - Insertion of Cardiac Lead into R Ventricle, Perc Approach 02HL3JZ - Insertion of Pacemaker Lead into L Ventricle, Perc Approach 02HL3JZ - Insertion of Pacemaker Lead into L Ventricle, Perc Approach 02HL3MZ - Insertion of Cardiac Lead into Left Ventricle, Perc 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, Perc Endo Approach 02PAXMZ - Removal of Cardiac Lead from Heart, External Approach

37.80 - Insertion of permanent pacemaker, initial or replacement, type of device not spec

0JH60PZ - Insert Card Rhythm Dev in Chest Subcu/Fascia, Open 0JH60PZ - Insert Card Rhythm Dev in Chest Subcu/Fascia, Open 0JH63PZ - Insert Card Rhythm Dev in Chest Subcu/Fascia, Perc 0JH63PZ - Insert Card Rhythm Dev in Chest Subcu/Fascia, Perc 0JH80PZ - Insert Card Rhythm Dev in Abd Subcu/Fascia, Open 0JH80PZ - Insert Card Rhythm Dev in Abd Subcu/Fascia, Open 0JH83PZ - Insert Card Rhythm Dev in Abd Subcu/Fascia, Perc 0JH83PZ - Insert Card Rhythm Dev in Abd Subcu/Fascia, Perc 0JPT0PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Open 0JPT3PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Perc

37.81 - Initial insertion of single-chamber device, not specified as rate responsive

0JH604Z - Insert Pace, Singl Cham in Chest Subcu/Fascia, Open 0JH634Z - Insert Pace, Singl Cham in Chest Subcu/Fascia, Perc 0JH804Z - Insert Pace, Singl Cham in Abd Subcu/Fascia, Open 0JH834Z - Insert Pace, Singl Cham in Abd Subcu/Fascia, Perc

37.82 - Initial insertion of single-chamber device, rate responsive

0JH605Z - Insert Pace, Singl Cham Rt Respn in Chest Subcu/Fascia, Open 0JH635Z - Insert Pace, Singl Cham Rt Respn in Chest Subcu/Fascia, Perc 0JH805Z - Insert Pace, Singl Cham Rt Respn in Abd Subcu/Fascia, Open 0JH835Z - Insert Pace, Singl Cham Rt Respn in Abd Subcu/Fascia, Perc

37.83 - Initial insertion of dual-chamber device

0JH606Z - Insert Pace. Dual Cham in Chest Subcu/Fascia, Open 0JH636Z - Insert Pace. Dual Cham in Chest Subcu/Fascia, Perc 0JH806Z - Insert Pace. Dual Cham in Abd Subcu/Fascia, Open 0JH836Z - Insert Pace. Dual Cham in Abd Subcu/Fascia, Perc

37.85 - Replacement of any type pacemaker device with single-chamber device, not spec

0JH604Z - Insert Pace, Singl Cham in Chest Subcu/Fascia, Open 0JH634Z - Insert Pace, Singl Cham in Chest Subcu/Fascia, Perc 0JH804Z - Insert Pace, Singl Cham in Abd Subcu/Fascia, Open 0JH834Z - Insert Pace, Singl Cham in Abd Subcu/Fascia, Perc 0JPT0PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Open 0JPT3PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Perc

ICD 10 Table for EP Procedures (continued) ICD-9 v3

ICD-10 PCS Equivalent Codes*

37.86 - Replacement of any type of pacemaker device with single-chamber device, rat

0JH605Z - Insert Pace, Singl Cham Rt Respn in Chest Subcu/Fascia, Open 0JH635Z - Insert Pace, Singl Cham Rt Respn in Chest Subcu/Fascia, Perc 0JH805Z - Insert Pace, Singl Cham Rt Respn in Abd Subcu/Fascia, Open 0JH835Z - Insert Pace, Singl Cham Rt Respn in Abd Subcu/Fascia, Perc 0JPT0PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Open 0JPT3PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Perc

37.87 - Replacement of any type pacemaker device with dual-chamber device

0JH606Z - Insert Pace. Dual Cham in Chest Subcu/Fascia, Open 0JH636Z - Insert Pace. Dual Cham in Chest Subcu/Fascia, Perc 0JH806Z - Insert Pace. Dual Cham in Abd Subcu/Fascia, Open 0JH836Z - Insert Pace. Dual Cham in Abd Subcu/Fascia, Perc 0JPT0PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Open 0JPT3PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Perc

00.50 - Implantation of cardiac resynchronization pacemaker without mention of defib

02H40JZ - Insertion of Pacemaker Lead into Cor Vein, Open Approach 02H43JZ - Insertion of Pacemaker Lead into Cor Vein, Perc Approach 02H44JZ - Insertion of Pace Lead into Cor Vein, Perc Endo Approach 02H60JZ - Insertion of Pacemaker Lead into Right Atrium, Open Approach 02H63JZ - Insertion of Pacemaker Lead into Right Atrium, Perc Approach 02H64JZ - Insertion of Pace Lead into R Atrium, Perc Endo Approach 02HK0JZ - Insertion of Pacemaker Lead into R Ventricle, Open Approach 02HK3JZ - Insertion of Pacemaker Lead into R Ventricle, Perc Approach 02HK4JZ - Insertion of Pace Lead into R Ventricle, Perc Endo Approach 02HL0JZ - Insertion of Pacemaker Lead into L Ventricle, Open Approach 02HL3JZ - Insertion of Pacemaker Lead into L Ventricle, Perc Approach 02HL4JZ - Insertion of Pace Lead into L Ventricle, Perc Endo Approach 0JH607Z - Insert Card Rsync Pace Puls Gen in Chest Subcu/Fascia, Open 0JH637Z - Insert Card Rsync Pace Puls Gen in Chest Subcu/Fascia, Perc 0JH807Z - Insert Card Rsync Pace Puls Gen in Abd Subcu/Fascia, Open 0JH837Z - Insert Card Rsync Pace Puls Gen in Abd Subcu/Fascia, Perc

00.53 - Implantation or replacement of cardiac resynchronization pacemaker pulse gen

0JH607Z - Insert Card Rsync Pace Puls Gen in Chest Subcu/Fascia, Open 0JH607Z - Insert Card Rsync Pace Puls Gen in Chest Subcu/Fascia, Open 0JH637Z - Insert Card Rsync Pace Puls Gen in Chest Subcu/Fascia, Perc 0JH637Z - Insert Card Rsync Pace Puls Gen in Chest Subcu/Fascia, Perc 0JH807Z - Insert Card Rsync Pace Puls Gen in Abd Subcu/Fascia, Open 0JH837Z - Insert Card Rsync Pace Puls Gen in Abd Subcu/Fascia, Perc 0JPT0PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Open 0JPT3PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Perc

37.75 - Revision of lead [electrode]

02WA0MZ - Revision of Cardiac Lead in Heart, Open Approach 02WA3MZ - Revision of Cardiac Lead in Heart, Percutaneous Approach 02WA4MZ - Revision of Cardiac Lead in Heart, Perc Endo Approach

37.77 - Removal of lead(s) [electrode] without replacement

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, Perc Endo Approach 02PAXMZ - Removal of Cardiac Lead from Heart, External Approach

37.79 - Revision or relocation of cardiac device pocket

0JWT0PZ - Revise Card Rhythm Dev in Trunk Subcu/Fascia, Open 0JWT3PZ - Revise Card Rhythm Dev in Trunk Subcu/Fascia, Perc

37.89 - Revision or removal of pacemaker device

0JPT0PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Open 0JPT3PZ - Remove Card Rhythm Dev from Trunk Subcu/Fascia, Perc 0JWT0PZ - Revise Card Rhythm Dev in Trunk Subcu/Fascia, Open 0JWT3PZ - Revise Card Rhythm Dev in Trunk Subcu/Fascia, Perc

37.98 - Replacement of automatic cardioverter/defibrillator pulse

0JH608Z - Insert of Defib Gen into Chest Subcu/Fascia, Open Approach 0JH638Z - Insert of Defib Gen into Chest Subcu/Fascia, Perc Approach

* A one-to-one match does not exist between codes in ICD-9-CM and ICD-10-CM. Use this General Equivalence Map by CMS to find an ICD-10 code or code combination that is generally equivalent to an ICD-9 code. Look in the corresponding section of the ICD-10-CM Tabular List of Diseases and Injuries to determine whether that code, or another code in that section, is the best choice.

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HCPCS Device Category C-Codes C-Code

Description

Pacemaker C1785

Pacemaker, dual chamber, rate-responsive (implantable)

C2621

Pacemaker, other than single or dual chamber (implantable)

C2620

Pacemaker, single chamber, non rate-responsive (implantable)

C1786

Pacemaker, single chamber, rate-responsive (implantable)

C2619

Pacemaker, dual chamber, non rate-responsive (implantable)

C1883

Adapter/extension, pacing lead or neurostimulator (implantable)

C1900

Lead, left ventricular coronary venous system

C1898

Lead, pacemaker, other than transvenous VDD single pass

C1779

Lead, pacemaker, transvenous VDD single pass

C2619

Pacemaker, dual chamber, non rate-responsive (implantable)

Leads

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Coverage for Pacemaker Procedures Centers for Medicare and Medicaid Services. National Coverage Determination for Cardiac Pacemakers (20.8). To review the NCD and NCA for Cardiac Pacemakers, please follow the links below for coverage: http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=267%20 http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=238&ncdver=2&CoverageSelection=National&KeyWord=pacemakers&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAABAAAAAAAA%3d%3d&

MEDICARE NCD FOR CARDIAC RESYNCHRONIZATION THERAPY PACEMAKERS (CRT-Ps) At this time there is no specific NCD for CRT-Ps. However, some MACs have developed Local Coverage Determinations (LCDs) for CRT-P that apply to certain regions. Providers are advised to check with their local MAC or non-Medicare payer(s) to determine patient coverage and coding/billing guidelines.

References CMS update: http://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Downloads/CMS-1601-FC-Addenda.zip ICD-9-CM Code Book - v29 FY2014 (Effective October 1, 2013) Medicare Coverage Database available at: https://www.cms.gov/medicare-coverage-database Current Procedural Terminology (CPT) © 2013 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.

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