Monday, April 05, 2010

Pacemakers and CERT Audits

Not only are doctors enjoying the prospects of a 21% pay cut this month, we're also beginning to see increase statistically-generated audits of our medical care directed solely from Medicare billing codes from 1996-2002 and applying them to 2010 practice patterns.

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).

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.
It seems if there are no symptoms, then no atrial lead is likely to be permitted.

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.

-Wes

6 comments:

Bob said...

Glad I got all three leads in before I reached medicare age. Isn't this where the pre-existing condition (or cure) is a benefit?

Keith said...

I would suggest to you that it is the willingness of some of your colleugues to put dual chamber pacemekers in every patient, regardless of the need or not, that is driving up the costs to Medicare and other insurers, and ultimately the patients, that brings about these onerous rules.

Are we to be so naive to imagine that indications for this expensive technology is not being stretched by many in your specialty? And what resort do payors have to control this abuse?

We could blame the current payment methodologies that reward all of us for quantity vs quality and certainly reward the most complex and complicated solution for every health care problem. Thus we have increasing frequency of dual chamber pacemaker placement, preferably with an ICD, that are growing in numbers and adding to our health care costs.

Frankly, my method of cost control would be to suggest paying the cardiologist the same whether he places a single or dual lead pacemaker. It would then be interesting to see the frequency of recommendation of dual pacing in relation to its current use.

I look forward to the new health care bills policies as hopefully bringing some sanity to the health care market and keeping us all from eventually paying 90% of our take home pay on health care. It strikes me we all have basic conflicts of interest under this current system (getting paid to do more regardless of whether it benefits the patient or not) that need to be ended. Then we will not have to endure tedious rules from insurance companies in deciding the proper and most cost efficient treatment for our patients

DrWes said...

Bob-

Isn't this where the pre-existing condition (or cure) is a benefit?

All that happens with CERT audits is they note an increase in Medicare billing codes, so this triggers an audit. The very fact that new indications for pacing (like congestive heart failure in patients with poor EF and LBBB) have arisen since the criteria in 1996-2002 were established means little to CMS. This increases the need for more paper work on the doctor's part because CMS is using antiquated data to base its audit information.

Keith -

We are all clearly fraudulent implanters in your eyes, it seems. No thought ever goes into physicians' consideration of indications for dual vs single chamber pacing. Dual pacers for everyone! Clearly doctors are the problem. What is stunning is how, in your eyes, the government will ALWAYS know what's best for our patients. Never mind that the government has only one mission when it comes to providing health care to the masses: cost control. Surely their conflicts at managing cost would NEVER conflict with what's best for a patient. Better to save MONEY on those old patients with complete heart block by placing a single chamber pacemaker up front because the doctor didn't document pacemaker syndrome symptoms, then let the patient have a later procedure to upgrade the pacemaker if needed. That way (according to the government) we can shift dollars to "prevention" as the way to save health care costs, despite serious lack of data with this approach. No doubt the government, with their current tort-reform efforts, will be right there when I am sued because that patient has to undergo two procedures instead of one.

Oh, and don't mention the data that demonstrates less afib burden with synchronous AV pacing in complete heart block compared to single-chamber pacing.

No, better to forget these data and follow the antiquated rules. After all, our central bureaucratic brethren always know what's best for our patients.

Anonymous said...

plus the approved indication for scd-heft was for single chamber devices. no additional payment for dual chamber icd's. yet plenty of dual chamber icd's going in, suggesting that physicians believe that the second lead will help (no additional payment for it, additional cost to hospital incurred, additional liability to physician).
of course keith might argue that those were inappropriate devices then.
i'm sure if the government goes through primary care docs follow up plans they will find similarly unnecessary visits that should not be paid for since they could have been handled in the first 15 minute visit, along with the other 7 problems that were addressed.

Thor said...

Just got hit with the dual chamber audit. CMS is using 1985 guidelines for this audit! In your experience/opinion, do I have any realistic chance of being reimbursed for those 50 pacemakers (or at least getting paid for a single chamber pacer instead of no payment)? Of course these were all appropriately indicated 2 ch PPMs.

DrWes said...

Thor-

Currently, Medicare uses 2005 recommendations for ICD implantation which were superseded by 2008 guidelines long ago (it's now 2011). This, regrettably, should place physicians on notice that the when government cost-cuts are needed there will be little incentive to adapt guidelines to new knowledge or doctor input, unless of course, the new recommendations limit expenditures.