No National Coverage Determination for Implanted Cardioverter Defibrillators

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.

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, 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, and the National Association of Healthcare Revenue Integrity, 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. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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