Medtronic
 
 

Heart Failure

Two Inpatient Coding and Reimbursement Updates for Cardiac Resynchonization Therapy Plus ICD Devices (CRT-D)

  1. CRT-D New Technology Add-On Payment
  2. Clarification on Heart Failure Diagnosis Sequencing

CRT-D New Technology Add-On Payment *

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What is the CMS CRT-D New Technology Add-On Payment?
In the Fall of 2003, Medtronic submitted a “New Technology Add-on Payment” application to the Centers for Medicare and Medicaid Services (CMS) for CRT-D devices. CMS approved the application and will begin reimbursing hospitals up to $16,262.50 for CRT-D inpatient cases in addition to their standard DRG payment. These add-on payments will be in place on Oct. 1, 2004 and are guaranteed for one year.

What are the eligibility requirements for the CRT-D New Technology Add-On Payment?

  • Only Medicare patients qualify
  • Only inpatient cases qualify
  • Only CRT-D devices are covered
    (see attached list of manufacturers and models)
  • Applicable to any case reimbursed under DRGs 115, 515, 535 and 536
  • One of the following ICD-9-CM procedure codes must be applicable:
        00.51 - CRT-D Total System Implant
        00.54 - CRT-D Implant or Replacement, Generator Only

How do I calculate the CRT-D New Technology Add-On Payment?
The new payment approved by CMS is an "add-on" to the base DRG. The range of the new payment is $0 to $16,262.50, depending on total billed charges, the hospital's operating cost to charge ratio (CCR) and the applicable DRG payment. The new payment "add-on" is calculated based on each individual claim involving a CRT-D procedure. Please download the attached Microsoft® Excel spreadsheet that contains a CRT-D New Technology Add-on Payment Calculator to see how the new payment formula would work in various hospital billing scenarios.

CRT-D New Technology Add-On Payment Calculator

*Federal Register (Aug. 11, 2004), 49013-490160 

Clarification on Heart Failure Diagnosis Sequencing

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Also, effective immediately, CMS has concurred with the American Health Information Management Association's (AHIMA) interpretation of office (coding) guidelines concerning the determination of heart failure as a principal diagnosis for CRT-D cases. As many coders have experienced, patients who receive CRT-D therapy normally have two indicated diagnoses: ventricular arrhythmia and heart failure. AHIMA stated:

"...(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.”

Therefore, if an operative report or medical record documented both "heart failure" and/or "ventricular arrhythmia" as the result occasion for hospital admission, heart failure could be used as the principal diagnosis, resulting in assignment to DRG 535. To make clear the dual diagnosis nature of CRT-D, physicians must be certain to document that heart failure was present and equally responsible for the hospital admission.

Additional Information