New RAC Issue for Cardiac Pacemakers

on Tuesday, 27 February 2018. All News Items | Recovery Auditor | Medicare Coverage | MAC Reviews

Coincidence or Honor?

What did you do in February related to the heart? Commit to eating better and exercising more for Heart Health Month, wear red on National Wear Red Day, give your sweetheart Valentines, or eat a lot of chocolate candy from a heart-shaped box?  Was it coincidence or in honor of Heart Month that the Medicare Recovery Auditors’ latest issue, released in February, was related to a heart procedure?

In February, all Recovery Auditors approved Issue Number 0078, a new complex review for Cardiac Pacemakers.  The issue description states, “Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.” Resources for additional information include National Coverage Determination (NCD) 20.8.3 and Local Coverage Articles addressing the billing and coding of pacemakers.  All of the Medicare Administrative Contractors (MACs) released an identical coverage article in 2016 after confusion related to the billing and coding of these services based on the then recently updated NCD.

The coverage articles clarified that the NCD guidelines only applied to the initial insertion of a cardiac pacemaker (CPT codes 33206, 33207, and 33208) and do not address replacement of pacemaker generators.  The articles listed the specific ICD-10 diagnosis codes (Group 1 codes) for the conditions covered by the NCD:

  • Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and
  • Documented non-reversible symptomatic bradycardia due to second degree and/or third degree
    atrioventricular block

The articles clarified significantly expanded coverage for pacemakers including

  • Group 2 codes - “contractor additional diagnosis codes” for certain AV and branch block, supraventricular tachycardia, and neurocardiogenic syncope codes,
  • Asymptomatic patients with certain conditions related to Group 1 and 2 diagnoses, and even
  • Medically necessary conditions not addressed by the NCD or Contractor that may be allowed.

Pacemaker procedure codes for conditions in or associated with Group 1 or 2 codes must be reported with a KX modifier attesting that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a permanent pacemaker. Medically necessary conditions not addressed by the NCD or Contractor should be reported with an SC modifier. 

Pacemaker claims that do not have a KX or SC modifier will be returned to provider as incomplete.
Pacemaker claims that do not meet the criteria for modifier KX or SC should have modifier GA or GZ appended (depending on ABN status) and will be denied.

CMS also recently added several proposed topics for RAC review that can be viewed here.  None of the proposed topics apply to hospital providers.

In other RAC news, CMS published an updated version of the Institutional Provider (Facilities) Additional Documentation Request (ADR) Limit document. The updated version includes additional information on how Provider Denial Rates are calculated, for Risk-Based, Adjusted ADR Limits.

Medicare will recalculate a provider’s denial rate after three (3) 45-day ADR cycles to reflect their compliance with Medicare rules.  The denial rate is the number of claims with overpayments divided by the total number of claims reviewed.  The new “Adjusted ADR Limit” based on the table below will be used for the next three (3) 45-day ADR cycles.

Denial Rate (Range)Adjusted ADR Limit (% of Total Paid Claims)
91-100% 5.0%
71-90% 4.0%
51-70% 3.0%
36-50% 1.5%
21-35% 1.0%
10-20% 0.5
4-9% 0.25%
0-3% No reviews for 3 (45-day) review cycles

Reduced ADR limits are an incentive for providers to be more compliant with Medicare rules in order to lower their RAC denial rates. This means compliant claims will result in fewer denials, fewer reviews going forward, and less stress on your heart.  One more thing you can do to be heart healthy.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it. .

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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