Coding, Coverage, and Reimbursement Resources
Cardiac Rhythm Disease Management
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Coverage

Medicare Coverage

Search the Medicare coverage database when looking for local or national coverage information.

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Medicare Coverage for Pacemakers, Implantable Cardiac Defibrillators and Cardiac Resynchronization Therapy Devices

Medicare National Coverage Determination (NCD)

Medicare has National Coverage Determinations for Single and Dual Chamber Pacemakers and Implantable Cardiac Defibrillators. The following resources relate to Medicare Coverage for Cardiac Rhythm Disease Management (CRDM) products and procedures.

Below are the links to the Medicare National Coverage Determinations for CRDM therapies.

Cardiac Pacemaker

CMS Publication 100.03: Medicare Coverage Issues Manual, §20.8.3

CMS also released two transmittals 2872 and 161 dated February 6, 2014.

Implantable Cardiac Defibrillators

CMS Publication 100-3, Manual, §20.4

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Electronic Analysis and Frequency Guidelines Including Transtelephonic Monitoring and Remote Follow-up

Pacemakers

Medicare National Coverage Determinations Manual (PDF, 631 KB)
See 20.8.1 and 20.8.1.1 – Cardiac Pacemakers (pages 20–22)

Implantable Cardioverter Defibrillators

Medicare has not issued national follow-up frequency guidelines for ICDs including transtelephonic monitoring and remote monitoring.

Medicare has not issued national frequency guidelines for ICDs, check for local Medicare policies. The 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities states every 3-6 months for ICD/CRT-D whether provided in person or remote, but more frequent evaluations may be required depending on the device characteristics and the patient’s clinical status.

Some local contractors have issued their own policies. Please contact your local contractor/payer for more information.

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Medtronic Resources for Cardiac Rhythm Disease Management Medicare Coverage Policies

Medtronic has published several resources to help you understand the coverage policies for CRDM products.

Guideline II Pacing Systems

Medtronic Cardiac Rhythm Disease Management – Guideline II Pacing Systems (PDF, 46 KB)
This document lists Medtronic pacemaker pulse generators and leads that fall under the Medicare Guideline II coverage policy. 3 pages.

Reimbursement Guide for ICD Implants

Reimbursement Guide for ICD Implants (PDF, 711 KB)
This guide has been developed to assist you in seeking coverage and payment for ICD and CRT-D therapies. It also provides hospital and physician coding information and some answers to frequently asked questions (FAQs).

2014 Advisa MRI Jan Update (PDF, 278 KB)
Hospital and physician coding for a Medicare patient receiving an MRI Scan

Private Payer Coverage Resources

Non-Medicare payers typically determine coverage for procedures based on prior authorization. With ICD patients, unless you are aware of the payer’s coverage policy for a specific patient population, we recommend that you contact the payer to seek prior authorization. If you ask about coverage after implant, it may result in unpaid claims, leaving both the hospital and the physician without compensation. Be sure to allow sufficient time to obtain prior authorization.

For more information related to private payers, visit the American Health Insurance Plans website.

CMS Fiscal Intermediary – Carrier Directory

To determine the applicable contractor for your state, access Medicare's Contacts Database at Medicare Directory.

Medicare A/B Contractor information is available at:

Fiscal Intermediary/MAC (PDF, 159 KB)

Carrier/MAC (PDF, 159 KB)

Information is available at the Medicare Contracting Reform page at CMS.gov.

Last updated: 2 Jul 2014

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