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Heart Failure

CRT-D Reimbursement Updates – FAQ

General CRT-D
CRT-D New Technology Add-on Payment
Clarification on CRT-D Diagnosis Sequencing

General CRT-D

What is CRT-D?
CRT-D is a type of biventricular pacing (helps both ventricles contract at the same time). Its indications differentiate CRT-D from other forms of pacing. In practical terms, patients with bradyarrhythmia receive a conventional pacemaker, patients with heart failure alone receive CRT-P (pacing alone) and patients with tachyarrhythmia alone receive a conventional implantable cardioverter defibrillator (ICD). To receive CRT-D, however, patients would have two indicated diagnoses: heart failure and ventricular tachyarrhythmia (VT).

What is a CRT-D device?
A CRT-D device is an ICD enabled with Cardiac Resynchronization Therapy (CRT). This device is implanted into a patient as part of a system that includes leads. Leads are specialized, thin, insulated wires that attach to the CRT-D device and deliver the therapy to the patient’s heart. CRT-D devices may also be referred to in physician operative notes by one of the following terms:

  • Bi-Ventricular Pacemaker with Defibrillator
  • Bi-V pacing with defibrillation
  • Bi-V ICD
  • High-power CRT
  • Heart failure pacemaker with defibrillator
  • Heart failure pacemaker with ICD

Who makes CRT-D devices?
Currently, CRT-D devices approved for use by the FDA are manufactured by only three companies: Medtronic, Guidant and St. Jude Medical.

CRT-D New Technology Add-on Payment

What is a New Technology Add-on Payment?
On October 1, 2001 The Centers for Medicare and Medicaid Services (CMS) established a mechanism to recognize the cost of new medical services and technologies under the hospital inpatient prospective payment system as a way of incorporating new services and technologies into the DRG system. In order for a new technology to qualify for such a payment, it must meet all of the following criteria:

  • Newness (2-3 year window following FDA approval)
  • Cost (established dollar threshold above DRG payment)
  • Proven substantial clinical improvement

Is it common for CMS to provide these payments?
No. This year, CMS rejected 8 out of 10 new technology add-on payment applications. Medtronic was successful in two of its applications – one for the Medtronic Kinetra deep brain stimulation device and the other for CRT-D devices.

What are the requirements for my hospital to qualify for a CRT-D add-on payment?
The CRT-D new technology add-on payments are provided on a case-by-case basis. In order to qualify, the case must involve the following:

  • Medicare covered inpatient admission
  • CRT-D device implantation (does not apply to standard ICDs or Pacemakers)
  • Accurate coding

What do you mean by “Accurate coding”?
In order for the case to qualify for an add-on payment, ICD-9-CM coding is critical.* If one of the following two codes are present, than the case will qualify:

  • ICD-9-CM 00.51 – CRT-D Total System Implant
  • ICD-9-CM 00.54 – CRT-D Implant or Replacement, Generator Only

How much is the CRT-D add-on payment worth?
The add-on payment is calculated on a case-by-case basis. The payment amount can range from $0 up to a maximum of $16,262.50. The actual payment for an individual case is roughly determined by the expected financial “loss” on that case. If the DRG payment adequately covers the cost to treat the patient, there is no payment. If the DRG payment is insufficient to cover the cost to treat the patient, than the add-on payment will equal half of the difference between the cost to treat the patient and the DRG payment up to a maximum of $16,262.50.

Can any company's CRT-D devices qualify for this payment?
Yes. When Medtronic decided to apply for this payment on behalf of our hospital customers, we wanted to make sure that hospitals could maximize their total benefit by ensuring that any CRT-D case could qualify. Accordingly, products from Medtronic, Guidant, and St. Jude Medical all qualify as long as they are CRT-D devices. Ask your Medtronic representative for a reference card that outlines all of the CRT-D devices currently approved for use in the US.

Is the CRT-D new technology add-on payment permanent?
No. The payment is only guaranteed from October 1, 2004 – September 30, 2005.

Clarification on CRT-D Diagnosis Sequencing

What are the coding challenges in CRT-D?
The fact that both an arrhythmia and a heart failure diagnosis would be present for CRT-D may lead to uncertainty in selection of the principal diagnosis. The circumstances of admission must be clearly documented to indicate the role both diagnoses play.

What are examples where the principal diagnosis might be in question?
A patient with underlying heart failure is admitted for device implantation. During the admission, an EP study is performed to identify which type of device is appropriate. As another example, a patient with a history of syncope is admitted with heart failure decompensation. Because of the syncope, monitoring is performed followed by an EP study. In both cases, the EP study establishes a diagnosis of ventricular tachycardia, and because of the patient’s co-existing heart failure, CRT-D is selected as the therapy.

Given that the physician implanting CRT-D is frequently an electrophysiologist, medical record documentation may appear to focus on the arrhythmia although heart failure contributed to the admission.

How can the principal diagnosis be selected most accurately?
To make clear the dual diagnosis nature of CRT-D, physicians must be certain to document that heart failure was present and a key factor in occasioning admissions in the examples above. When heart failure is chiefly responsible for occasioning the admission, heart failure is the principal diagnosis. When the circumstances of admission document that both conditions are equally responsible, either one may be selected* as the principal diagnosis according to the ICD-9-CM Official Guidelines for Coding and Reporting.1

What support exists for this?
The American Health Information Management Association (AHIMA), the professional association of medical record administrators and hospital coders interpreted the official coding guidelines in a comment on CMS's proposed rule, saying the following:

“...(we) believe that coders would follow the ICD-9-CM Official Guidelines for Coding and Reporting when sequencing the principal diagnosis for admissions involving cardiac resynchronization therapy. If the reason for admission were heart failure, then that condition would be sequenced as the principal diagnosis. When two conditions are equally responsible for the admission, the ICD-9-CM Official Guidelines for Coding and Reporting allow either condition to be sequenced as the principal diagnosis. In that case, the condition resulting in the higher-weighted DRG adjustment would likely be sequenced as the principal diagnosis.”2

In Section II 3 b of the Final IPPS Rule, issued August 2, 2004, CMS concurred with the diagnosis sequencing logic addressed by AHIMA.

Why does the principal diagnosis matter for CRT-D implants?
In 2003, defibrillator DRGs and their associated description changed. When a patient has a principal diagnosis of heart failure (HF), acute myocardial infarction (AMI), or Shock, an EP study and CRT-D implant will result in assignment to DRG 535. However, if HF, AMI or Shock is not indicated as a principal diagnosis, it results in assignment to DRG 536, a lower paying DRG. Because a DRG assignment is based on the principal diagnosis, if heart failure is applicable and appropriately documented within the medical record or operative report, its presence as a principal diagnosis will result in a higher paying DRG for the hospital.

References

*The decision on which code to use is at the discretion of the billing entity. This information is provided as a courtesy.
1Section II of ICD-9-CM Official Guidelines for Coding and Reporting: Selection of Principal Diagnosis(es) for Inpatient, Short-term, Acute Care, and Long Term Care Hospital Records:

B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis. When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

C. Two or more diagnoses that equally meet the definition for principal diagnosis. In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.

2See www.ahima.org/dc/ahimacommentsIP-pps05.cfm. Used with permission from AHIMA.

Additional Information