Here's a news release we received last week about dual chamber pacemakers:
National Government Services has recently received denials resulting from Comprehensive Error Rate Testing (CERT) audits of medical records for implantation of dual-chambered cardiac pacemakers. Denials for these types of claims can be very costly. In an effort to help decrease such denials, National Government Services would like to provide some information. The Centers for Medicare & Medicaid Services (CMS) published guidelines for coverage in the CMS Internet-Only Manual (IOM) Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 20.8, Cardiac Pacemakers, (437 KB) specifically Group II: Dual-Chambered Cardiac Pacemakers (effective since May 1985). We also would like to provide examples of denials we received from the CERT contractor.It appears government regulators will be auditing charts for evidence of the need for an atrial lead implantation in patients requiring dual chamber pacemakers for complete heart block or in cases of tachycardia/bradycardia syndrome. Coording to this release, examples of denials for dual chamber pacemakers have included:
Example 1: Beneficiary had a single chamber pacemaker for complete heart block which is covered by NCD 20.8. Replacement of a single chamber pacemaker with a dual chamber pacemaker requires documentation of NCD criteria such as “pacemaker syndrome” or ventricular asynchrony or the medical need based on cardiac status (needs to have atrial pacing in addition to a ventricular).It seems if there are no symptoms, then no atrial lead is likely to be permitted.
Example 2: The beneficiary’s predominant rhythm was atrial fibrillation with mention of bradycardia. The medical record is not sufficiently documented to show the heart rates and their correlation to the beneficiary's symptoms. For example the beneficiary's reported symptom of sweating but the symptom is not correlated to Holter monitor findings.
Example 3: The beneficiary had a history of atrial fibrillation and was treated with Coumadin. In addition the beneficiary had a history of prominent right heart failure and severe tricuspid regurgitation suggesting the beneficiary may have right atrial enlargement. The beneficiary had no history of prior pacemaker insertion. Dual chamber pacemaker was not supported in this case based upon the requirements listed in the NCD.
Example 4: Clinical findings of a history of hypertension, hyperlipidemia, and a Holter monitor indicating Tachy/brady syndrome. The beneficiary denied any SOB, dizziness, syncope, chest pain, weakness or fatigue. CMS criteria for single chamber pacemaker per the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 20.8, Cardiac Pacemakers, (437 KB) not met for dual or single chamber pacemaker.
So how to avoid these denials?
Document, document, document, and then document some more.
Still, despite adequate documentation, look for more time, expense and hassles to complete the CMS Medicare Determination Request Forms that are sure to come our way as we try to dispute these statistically-generated denials for our patients.
Funny how these costs of these administrative hassles are never tallied by CBO estimates of the cost of providing government-directed health care. Then again, given the $500-billion of Medicare cuts we are to expect from Medicare, this has been the plan all along.