37.71 Initial insertion of transvenous lead (electrode) into ventricle
02HK3JZ Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Approach
37.72 Initial insertion of transvenous leads (electrodes) into atrium and ventricle
02H63JZ Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach
02HK3JZ Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Approach
37.73 Initial insertion of transvenous lead (electrode) into atrium
02H63JZ Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach
37.76 Replacement of transvenous atrial and/or ventricular lead(s) (electrode)
02H63JZ Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach
02HK3JZ Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Approachplus (for replacement)
02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous Approach
02PAXMZ Removal of Cardiac Lead from Heart, External Approach
37.74 Insertion or replacement of epicardial lead (electrode) into epicardium
02HN0JZ Insertion of Pacemaker Lead into Pericardium, Open Approach
02HN4JZ Insertion of Pacemaker Lead into Pericardium, Percutaneous Endoscopic Approach plus (for replacement)
02PA0MZ Removal of Cardiac Lead from Heart, Open Approach
02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic Approach
37.81 Initial insertion of single-chamber device, not specified as rate responsive
0JH604Z Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH634Z Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH804Z Insertion of Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH834Z Insertion of Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
37.82 Initial insertion of single-chamber device, rate responsive
0JH605Z Insertion of Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH635Z Insertion of Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH805Z Insertion of Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH835Z Insertion of Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
37.83 Initial insertion of dual-chamber device
0JH606Z Insertion of Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH636Z Insertion of Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH806Z Insertion of Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH836Z Insertion of Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
37.85 Replacement of any type pacemaker device with single-chamber device, not specified as rate responsive
0JH604Z Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH634Z Insertion of Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH804Z Insertion of Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH834Z Insertion of Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach plus (for replacement)
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
37.86 Replacement of any type pacemaker device with single-chamber device, rate responsive
0JH605Z Insertion of Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH635Z Insertion of Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH805Z Insertion of Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH835Z Insertion of Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approachplus (for replacement)
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
37.87 Replacement of any type pacemaker device with dual-chamber device
0JH606Z Insertion of Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH636Z Insertion of Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH806Z Insertion of Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH836Z Insertion of Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach plus (for replacement)
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
37.75 Revision of lead (electrode)
02WA0MZ Revision of Cardiac Lead in Heart, Open Approach
02WA3MZ Revision of Cardiac Lead in Heart, Percutaneous Approach
02WA4MZ Revision of Cardiac Lead in Heart, Percutaneous Endoscopic Approach
37.77 Removal of lead(s) (electrode) without replacement
02PA0MZ Removal of Cardiac Lead from Heart, Open Approach
02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous Approach
02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic Approach
02PAXMZ Removal of Cardiac Lead from Heart, External Approach
37.78 Insertion of temporary transvenous pacemaker system
5A1213Z Performance of Cardiac Pacing, Intermittent
5A1223Z Performance of Cardiac Pacing, Continuous
37.79 Revision or relocation of cardiac device pocket
0JWT0PZ Revision of Cardiac Rhythm Related Device in Trunk Subcutaneous Tissue and Fascia, Open Approach
0JWT3PZ Revision of Cardiac Rhythm Related Device in Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
37.89 Revision or removal of pacemaker device
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
0JWT0PZ Revision of Cardiac Rhythm Related Device in Trunk Subcutaneous Tissue and Fascia, Open Approach
0JWT3PZ Revision of Cardiac Rhythm Related Device in Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach

CARDIAC RESYNCHRONIZATION SYSTEM (CRT-P)

00.50 Implantation of cardiac resynchronization pacemaker without mention of defibrillation, total system (CRT-P) 02H43JZ Insertion of Pacemaker Leadinto Coronary Vein, Percutaneous Approach plus/or
02H63JZ Insertion of Pacemaker Lead into Right Atrium, Percutaneous Approach plus/or
02HK3JZ Insertion of Pacemaker Lead into Right Ventricle, Percutaneous Approach plus/or
02HN0JZ Insertion of Pacemaker Lead into Pericardium, Open Approach
02HN4JZ Insertion of Pacemaker Lead into Pericardium, Percutaneous Endoscopic Approach plus
0JH607Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH637Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH807Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH837Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach
00.53 Implantation or replacement of cardiac resynchronization pacemaker, pulse generator only (CRT-P)
0JH607Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Open Approach
0JH637Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach
0JH807Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach
0JH837Z Insertion of Cardiac Resynchronization Pacemaker Pulse Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach plus(for replacement)
0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach
0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach
00.52 Implantation or replacement of transvenous lead (electrode) into left ventricular coronary venous system
02H43JZ Insertion of Pacemaker Lead into Coronary Vein, Percutaneous Approach plus(for replacement)
02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous Approach

ELECTROPHYSIOLOGY

37.26 Catheter based invasive electrophysiologic testing
4A023FZ Measurement of Cardiac Rhythm, Percutaneous Approachplus (if used)
3E053KZ Introduction of Other Diagnostic Substance into Peripheral Artery, Percutaneous Approach
3E063KZ Introduction of Other Diagnostic Substance into Central Artery, Percutaneous Approach plus (if performed)
37.27 Cardiac mapping 02K83ZZ Map Conduction Mechanism, Percutaneous Approach
37.20 Noninvasive programmed electrical stimulation (NIPS)
4A02X4Z Measurement of Cardiac Electrical Activity, External Approach
4A02XFZ Measurement of Cardiac Rhythm, External Approach

DEVICE MONITORING

89.45 Artificial pacemaker rate check 4B02XSZ Measurement of Cardiac Pacemaker, External Approach
89.46 Artificial pacemaker artifact wave form check
4B02XSZ Measurement of Cardiac Pacemaker, External Approach
89.47 Artificial pacemaker electrode impedance check
4B02XSZ Measurement of Cardiac Pacemaker, External Approach
89.48 Artificial pacemaker voltage or amperage threshold check

4B02XSZ Measurement of Cardiac Pacemaker, External Approach




Permanent cardiac pacemakers refer to a group of self-contained, battery operated, implanted devices that send electrical stimulation to the heart through one or more implanted leads. They are often classified by the number of chambers of the heart that the devices stimulate (pulse or depolarize). Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle.

The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization. A catheter is inserted into the chest and the pacemaker’s leads are threaded through the catheter to the appropriate chamber(s) of the heart. The surgeon then makes a small “pocket” in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with stitches.

The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to conclude that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion).







Professional claims


Claims with dates of service on and after August 13, 2013, for implanted permanent cardiac
pacemakers, single chamber or dual chamber, are covered if submitted with one of the
following Procedure codes: 33206, 33207, or 33208, and that contain at least one of the following
ICD-9/ICD-10 diagnosis codes (upon ICD-10 implementation) listed below in addition to the –
KX modifier:

• 426.0 Atrioventricular block, complete/ I44.2 Atrioventricular block, complete;
•426.12 Mobitz (type) II atrioventricular block/ I44.1 Atrioventricular block, second degree;
•426.13 Other second degree atrioventricular block/ I44.1 Atrioventricular block, second degree;
•427.81 Sinoatrial node dysfunction/ I49.5 Sick sinus syndrome; or
•746.86 Congenital heart block/ Q24.6 – Congenital heart block.

The following diagnosis codes can be covered at your MACs discretion if submitted with at least one of the Procedure codes and diagnosis codes listed above in addition to the –KX modifier:

• 426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block;
•426.11 First degree atrioventricular block/ I44.0 Atrioventricular block first degree;
•426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block/ I45.19 Other right bundle-branch block;
•427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia;
•427.31 Atrial fibrillation/ I48.1 Persistent atrial fibrillation/ I48.91, Unspecified atrial fibrillation;
•427.32 Atrial flutter/ I48.3 Typical atrial flutter/ I48.4 Atypical atrial flutter or I48.91 Unspecified atrial fibrillation; or
•780.2 Syncope and collapse/R55 Syncope and collapse (R55 is the ICD-10 dx code but is not payable upon implementation of ICD-10 and is only included here for information purposes).

Institutional claims 
For coverage of claims with dates of service on and after August 13, 2013, for implanted permanent cardiac pacemakers, single chamber or dual chamber, using HCPCS codes:

C1785, C1786, C2619, C2620, 33206, 33207, or 33208, the claim must contain at least one of the following procedure codes:

•37.81 Initial insertion of single chamber device, not specified as rate responsive
•37.82 Initial insertion of single chamber device, rate responsive
•37.83 Initial insertion of single chamber device and at least one of the following diagnosis codes in addition to the –KX modifier:
•426.0 Atrioventricular block, complete;
•426.12 Mobitz (type) II atrioventricular block;
•426.13 Other second degree atrioventricular block;
•427.81 Sinoatrial node dysfunction; or
•746.86 Congenital heart block.

The following diagnosis codes can be covered, at the MAC’s discretion, if submitted with at
least one of the diagnosis codes listed above in addition to the –KX modifier:

•426.10 Atrioventricular block, unspecified/ I44.30 Unspecified atrioventricular block;
•426.11 First degree atrioventricular block/ I44.0 Atrioventricular block first degree;
•426.4 Right bundle branch block/ I45.10 Unspecified right bundle-branch block/ I45.19 Other right bundle-branch block;
•427.0 Paroxysmal supraventricular tachycardia/ I47.1 Supraventricular tachycardia;
•427.31 Atrial fibrillation/ I48.1 Persistent atrial fibrillation/ I48.91, Unspecified atrial fibrillation;
•427.32 Atrial flutter/ I48.3 Typical atrial flutter/ I48.4 Atypical atrial flutter or I48.91 Unspecified atrial fibrillation; or
•780.2 Syncope and collapse/R55 Syncope and collapse (R55 is the ICD-10 dx code but is not payable upon implementation of ICD-10 and is only included here for informationpurposes).

Diagnosis Code Crosswalk : ICD-9-CM to ICD-10-CM

Cardiac Rhythm and Heart Failure Diagnoses


ICD-9-CM ICD-10-CM

402.01 Hypertensive heart disease, malignant, with heart failure
I11.0 Hypertensive heart disease with heart failure

402.11 Hypertensive heart disease, benign, with heart failure
402.91 Hypertensive heart disease, unspecified, with heart failure

404.01 Hypertensive heart and chronic kidney disease, malignant, with heart
failure and with chronic kidney disease stage I through stage IV, or unspecified

Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified

404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified

404.03 Hypertensive heart and chronic kidney disease, malignant, with heart
failure and with chronic kidney disease stage V or end stage renal disease
Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease

404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease
412 Old myocardial infarction
I25.2 Old myocardial infarction
414.8 Other specified forms of chronic ischemic heart disease (used for ischemic cardiomyopathy)
I25.5 Ischemic cardiomyopathy
425.11 Hypertrophic obstructive cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
425.4 Other primary cardiomyopathies
I42.0 Dilated cardiomyopathy (congestive)
I42.5 Other restrictive cardiomyopathy (constrictive cardiomyopathy)
I42.8 Other cardiomyopathies
I42.9 Cardiomyopathy, unspecified
426.0 AV block, complete
I44.2 Atrioventricular block, complete
426.10 AV block, unspecified
I44.30 Unspecified atrioventricular block
426.11 AV block, first degree
I44.0 Atrioventricular block, first degree
426.12 AV block, Mobitz II
I44.1 Atrioventricular block, second degree

426.13 AV block, other second degree

MEDICARE NCD FOR CARDIAC RESYNCHRONIZATION THERAPY PACEMAKERS (CRT-PS)

A cardiac resynchronization therapy pacemaker (CRT-P) utilizes biventricular pacing to coordinate the contraction of the ventricles with the intent of improving the hemodynamic status of the patient. This technology utilizes both conventional pacing technology as well as the addition of a third electrode that provides sensing and pacing capabilities in the left ventricle. At this time there is no specific NCD for CRT-Ps. However, some MACs have developed Local Coverage Determinations (LCDs) for CRT-P that apply to certain regions. It is important for medical providers to check with their local MAC for non-Medicare payer(s) to determine patient coverage and coding/billing guidelines.

MEDICARE NCD FOR INTRACARDIAC ELECTROPHYSIOLOGY AND RELATED PROCEDURES

Some cardiovascular procedures, such as pacemakers and cardioverter-defibrillators, contain very clear national coverage criteria as defined by CMS. Other procedures, such as electrophysiology studies (EPS), do not have clearly defined coverage criteria at the national level. Some MACs have developed Local Coverage Determinations (LCDs) for EPS that apply to certain regions. It is important for providers to check with their local MAC or non-Medicare payer(s) to determine patient coverage and coding/billing guidelines.

Pacemaker Implant Procedure 

The implant of a permanent pacemaker system requires the use of a pacemaker pulse generator and one electrode or lead for a single chamber system, or two electrodes or leads for a dual chamber system. The leads monitor and deliver electrical stimulation to the right atrium or right ventricle for a single chamber system, or both the right atrium and right ventricle for a dual chamber system. The lead(s) are inserted through the subclavian vein and are positioned in the right atrium and/or right ventricle. In some cases, the cephalic or internal jugular vein may be used as an alternative to the subclavian vein


A STEP-BY-STEP DESCRIPTION OF A TYPICAL INITIAL PACEMAKER SYSTEM IMPLANT PROCEDURE

1. The subclavian vein is accessed and a pulse generator pocket is formed.

2. Under fluoroscopy, the pacing lead(s) are inserted into the right atrium (33206) or right ventricle (33207) for a single chamber system, or into the right atrium and right ventricle for a dual chamber system (33208).

3. Lead measurement tests, including pacing and sensing thresholds and lead impedances, are performed.

4. The pacemaker pulse generator (included in 33206, 33207, and 33208) is connected to the lead(s) that are in place.

5. Additional testing of the lead(s) is completed.

6. The lead(s) and device are secured and the pulse generator pocket is closed.

Professional claims 


MACs shall return claims lines for implanted permanent cardiac pacemakers, single chamber or dual chamber, containing one of the following Procedure codes: 33206, 33207, or 33208, as unprocessable when the -KX modifier is not present. When returning such claims, MACs shall use the following messages:

• Claim Adjustment Reason Code (CARC) 4 – The procedure code is inconsistent with the modifier used or a required modifier is missing.

• Remittance Advice Remarks Code (RARC) N517 – Resubmit a new claim with the requested information.

Institutional claims


MACs shall return to providers claims for implanted permanent cardiac pacemakers, single chamber or dual chamber, when any of the following are not present on the claim:

At least  one HCPCS code: C1785, C1786, C2619, or C2620, at least one Procedure code: 33206, 33207,