Monday, July 07, 2014

New CMS National Coverage Decision for Pacemakers Begins Today

A new CMS National Coverage Decision for pacemakers begins today.  Here are the specifics.

If your patient is getting a pacemaker for atrial fibrillation or other "ineffective atrial contractions" with symptomatic bradycardia, be very sure to document the "non-reversible" nature of the symptomatic bradycardia in your note and have your billing staff consider adding a "KX" modifier to the claim line(s).

Remember, most regulators look at codes, not notes.

Just sayin' -



Anonymous said...

My husband was brutally coerced into getting an unnecessary pacemaker for "irreversible bradycardia" that had vanished by the time of the operation (they only started dishing out adequate lasix for his acute flutter-associated heart failure after he signed the form). They also installed it disastrously wrong, resulting in a further malpractice cascade - for which we didn't sue, please note. Too many electros feel very free to cram devices into anyone with a blip on the [questionably beneficial] telemetry. In my humble opinion some kind of crackdown is well warranted, not just to save tax dollars but to save patients from months of disability and lifetimes of risk.

Ronald Hirsch, MD said...

The NCD effective date was actually just delayed, although the new criteria for a pacemaker were actually effective in August, 2013. I suspect the NCD was delayed due to clarification on the billing technicalities.

Anonymous said...

"Brutally coerced"?

Anonymous said...

Oh yeah, coercion, don't doubt it. He was told by a whole pack of white coats that he could never get better, HAD to have the device, had NO choice, and "we wouldn't feel comfortable LETTING you leave without a pacemaker". Reasonable questions I asked about this prognosis were ignored, and when he was magically cured by belated correct drug treatment shortly before the procedure, the doctors cut off all contact. Down to the moment when he was on the table - and indeed afterward - we kept finding aspects of the planned procedure they had lied about or concealed to forestall our objections. His consent was thus both coerced and not informed, as we were told nothing of the medium-term disability or large permanent risks involved. Still, I did try to talk my husband into refusing, but I feared to insist, and he feared that if he ultimately needed it he would have been treated badly for being uppity.

Coercion step two: They gave him a small right pneumothorax during the procedure. It had no symptoms, yet the attending electro threatened to prevent him from leaving until he had submitted to a chest tube, probably because the air visible on X-ray was evidence of an additional level of malpractice by himself or a trainee. I think it was then that we started talking about leaving AMA, and a male nurse informed us that the insurance company would be told to refuse to pay for any of his care, leaving us financially ruined. (I replied, indirectly but interpretably, that if he was forced to submit to the unneeded tube and the resulting cascade killed him, I would kill the responsible MD. I would have done so, by the way. Fortunately the nurse did not report me!)

Coercion step zero: Before my husband had been cardioverted or adequately medicated for acute heart failure, when he could not lie down or sleep and was exhausted and weak, two electros repeatedly tried to brutalize him into consenting to not just a pacemaker, but an ICD. (We later learned that guidelines specifically discouraged ICD implantation in those circumstances, and that one of those staffers gets big money to publish clinical studies on ICD implantation.) That much he did have the backbone to refuse. On top of more never-get-better rhetoric, they literally yelled in his face, called him stupid, and showed sneering contempt for his objection that there might be circumstances in which he would not want to be defibrillated.

The outcome of my husband's case was that when the poorly implanted pacemaker caused very severe arrhythmia, another electro dished out two useless ablations, then cut it out only on the condition that he stuck it back in, finally grudgingly turned it down as far as possible, promised us an explantation, then let his partners yank the rug out from under it. My husband should have had a lawyer try to get him an explantation, but he didn't have the stomach for the fight, so now he just gets to live with the lifelong risk of potentially crippling tricuspid regurgitation - reported as occurring in 25% of implantees, up to 38% in a large study out this week. If he ever discovered that he had right-sided heart failure, believe me, he knows that if he's denied or won't risk a late lead extraction, he's better off eating a bullet when the time comes than submitting to any other form of intervention whatsoever. But if he has that now he's not likely to find out, because after all he's been put through - I give you a relatively brief summary that does not cover all the abuses and errors by any means - he says he will never see another cardiologist again.

That's what I, to reverse a phrase used by our host, like to call "hostile independency". I have been seething with rage for years over what I witnessed him suffering, and every time it affects our lives for the worse I seethe all over again. My own advance directive says that never, under any circumstances, is anything to be put into my body that I can't get out by myself.