Home » CRM Health Economics & Reimbursement » CMS Coverage Guidelines » Cardiac Pacemaker Evaluation Services
Last updated: July 2007
Effective date of this version: October 1, 1984
Diagnostic Services in Outpatient Hospital
Diagnostic Tests (other)
(Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.)
Diagnostic Tests, X-rays, and Lab Services
There are two general types of pacemakers in current use-single-chamber pacemakers, which sense and pace the ventricles of the heart, and dual-chamber pacemakers which sense and pace both the atria and the ventricles. These differences require different monitoring patterns over the expected life of the units involved.
Medicare covers a variety of services for the post-implant follow-up and evaluation of implanted cardiac pacemakers. The following guidelines are designed to assist contractors in identifying and processing claims for such services.
Note: These new guidelines are limited to lithium battery-powered pacemakers, because mercury-zinc battery-powered pacemakers are no longer being manufactured and virtually all have been replaced by lithium units. Contractors still receiving claims for monitoring such units should continue to apply the guidelines published in 1980 to those units until they are replaced.
One fact of which contractors should be aware is that many dual-chamber units may be programmed to pace only the ventricles; this may be done either at the time the pacemaker is implanted or at some time afterward. In such cases, a dual-chamber unit, when programmed or reprogrammed for ventricular pacing, should be treated as a single-chamber pacemaker in applying screening guidelines.
The decision as to how often any patient's pacemaker should be monitored is the responsibility of the patient's physician who is best able to take into account the condition and circumstances of the individual patient. These may vary over time, requiring modifications of the frequency with which the patient should be monitored. In cases where monitoring is done by some entity other than the patient's physician, such as a commercial monitoring service or hospital outpatient department, the physician's prescription for monitoring is required and should be periodically renewed (at least annually) to assure that the frequency of monitoring is proper for the patient. Where a patient is monitored both during clinic visits and transtelephonically, the contractor should be sure to include frequency data on both types of monitoring in evaluating the reasonableness of the frequency of monitoring services received by the patient.
Since there are over 200 pacemaker models in service at any given point, and a variety of patient conditions that give rise to the need for pacemakers, the question of the appropriate frequency of monitorings is a complex one. Nevertheless, it is possible to develop guidelines within which the vast majority of pacemaker monitorings will fall and contractors should do this, using their own data and experience, as well as the frequency guidelines which follow, in order to limit extensive claims development to those cases requiring special attention.
Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. Medicare does not preauthorize services, however, coverage policies and criteria may be found on contractor web sites or by contacting your local Medicare carrier/fiscal intermediary. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your ICD-9-CM and AMA CPT manuals for appropriate coding options. When performing multiple procedures, review current correct coding guidelines carefully. Services that are considered a component of another procedure cannot always be coded and billed separately. Medicare's Correct Coding Initiative is reviewed and updated several times a year. Commercial (non-Medicare) payer policies vary and should be carefully reviewed.