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Coding, Coverage, and Reimbursement Resources

Cardiac Rhythm and Heart Failure

Coverage

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Medicare

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 and Heart Failure (CRHF) products and procedures.

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

Cardiac Pacemaker

CMS Publication 100.03: Medicare Coverage Issues Manual, §20.8.3

The effective date of the National Coverage Determination (NCD) for Single and Dual Chamber Permanent Pacemakers is August 13, 2013. However, on January 27, 2016 the Medicare Learning Network (MLN) Matters® released Revised MM9078. This article includes the following key highlights:

  • To address claims processing issues, CMS has instructed MACs to implement this NCD at the local level until CMS revises the formal claims processing instructions.

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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New Medicare Centralized Investigational Device Exemption (IDE) Coverage Process

Medtronic prepared a brief summary of the changes associated with the New Medicare Centralized IDE Coverage Process. (PDF, 157 KB)

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Medtronic Resources for Cardiac Rhythm and Heart Failure (CRHF) Medicare Coverage Policies

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

Guideline II Pacing Systems

Medtronic Cardiac Rhythm and Heart Failure (CRHF) – Guideline II Pacing Systems (PDF, 119 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, 887 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). 24 Pages.

Coding for a Patient Receiving an MRI Scan (PDF, 216 KB)
Hospital and physician coding for a Medicare patient receiving an MRI Scan

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Private Payer

Fiscal Intermediary – Carrier Directory