Updated on: March 13, 2018

No National Coverage Determination for Implanted Cardioverter Defibrillators

By
Original story posted on: March 12, 2018

  • Product Headline: Cardiac Procedures Part II: ICDs, Watchman Devices, and Cardiac Stents
  • Product Image: Product Image
  • Product Description:
    LIVE WEBCAST
    REGISTER NOW

For implanted cardioverter defibrillators, (ICDs) there is no national coverage determination (NCD), nor is there an implementation date.

 
As we have reported in past editions of RACmonitor eNews, the national coverage determination (NCD) for placement of implanted cardioverter defibrillators (ICDs) was recently updated. As I reported last week, the changes to the NCD, which were announced in a final decision memo issued Feb. 15, were effective immediately.
 
But I was contacted by a loyal RACmonitor reader, Kim Johnson from Honor Health in Arizona, who pointed out that NCD 20.4 on the website of the Centers for Medicare & Medicaid Services (CMS) has yet to be updated. She also noted that there was no change request issued by CMS, so not only do we not have a new published NCD, but we also do not yet have an implementation date.

What is the difference between an effective date and an implementation date? The effective date is the date upon which all the criteria outlined in the policy must be followed. For the NCD for ICDs, that means the new added medical necessity criteria may be used, such as using cardiac MRI to establish the ejection fraction, and hospitals have the option of discontinuing reporting their data to a registry.
 
The implementation date is the date upon which the Medicare Administrative Contractors will be prepared to properly process the claims based on the criteria outlined in the new NCD. For ICDs, the current claim processing instructions require the presence of the -QR modifier on every outpatient claim to indicate that the hospital reported the ICD data to a registry. If the -QR modifier is not present, the claim will automatically be denied. 
 
So since the NCD no longer requires reporting to a registry, a hospital may choose to stop reporting, eliminating a substantial expense and reducing the workload of the staff, who no longer need to abstract the data and input it into the registry. But if they stop reporting to the registry, they will no longer be able to place the -QR modifier on the claims. And without that modifier, the claim will be rejected.

Most of the new NCD requirements, such as use of cardiac MRI, can be adopted immediately since there is no claim edit involved. If a claim undergoes complex review, the reviewer should be referencing the new NCD requirements and should not deny payment.
 
But registry reporting and the -QR modifier pose the problem. Hospitals therefore have two choices. The first option would be to continue to pay for registry membership, burden your staff with an unnecessary data collection task so you can report to the registry, continue to place the -QR modifier on the claim, and continue to get paid. Or stop registry reporting and prepare the claims without the -QR modifier, but then hold all the claims until after the implementation date when MACs have implemented the changes, at which point they may be released for processing.
 
If this was a low-cost, infrequent intervention, the decision would be easy. But with a base reimbursement rate of $30,960, a hospital with an active electrophysiology program could have a substantial amount of money at stake, and an unhappy finance department with a large amount in the “discharged but not final billed” category on their books.

Once again, my best advice is to determine what is best for your hospital and choose that.


Comment on this article
Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

Related Stories

  • Things Your Mother Never Told You About HCC: Version 23
    The 2019 CMS risk adjustment model is version 23. The Centers for Medicare & Medicaid Services (CMS) released, in April, the latest update to the CMS-hierarchical condition category (HCC) Risk Adjustment Model (V23).  It applies to payment year 2019.  As…
  • Digesting the Medicare Physician Fee Schedule for 2019
    CMS issued the final rule on Nov. 1. The Centers for Medicare & Medicaid Services (CMS) final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (MPFS) on or…
  • “Shock and Awe:” The 2019 MPFS
    CMS released the MPFS on Nov. 1, ending months of turmoil. The Centers for Medicaid & Medicare Services (CMS) released the final rule on the Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP) on Nov. 1. The…