The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Resynchronization Therapy (CRT) L39080.
Services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules. Refer to the related LCD for reasonable and necessary requirements and limitations.
It is well-established that indications for CRT are based upon left ventricle (LV) ejection fraction (EF), QRS duration, QRS morphology, New York Heart Association (NYHA) functional class, and the need for ventricular pacing, if applicable. Therefore, it is important that all these attributes be documented within the patient’s medical record. Documentation detailing the risk-benefit equation for any given patient must be clear. Each patient has specific characteristics such as age, heart failure (HF) impact on quality of life, personal preferences, or a left/right predominance to a non-left bundle branch block (LBBB) scenario, etc. that may play a role in choice of treatment. Such unique issues should be documented.
Medical record documentation should also reflect a beneficiary who is on a stable pharmacologic regimen for HF before CRT implantation. This regimen may include any of the following, unless contraindicated: angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, beta blocker, digoxin, or diuretics.
The implanted CRT device must be United States Food and Drug Administration (FDA) approved for the CRT indication.
Necessary documentation elements for a patient in whom CRT implantation is planned:
- Most recent EF measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiography
- QRS duration in milliseconds (ms)
- QRS morphology such as LBBB, non-LBBB (with additional clarifying comments as applicable), right bundle branch block (RBBB)
- If present, any markedly prolonged first degree atrioventricular (AV) block or second- or third-degree AV block
- Any plan for AV nodal ablation
- NYHA class and any trends up or down within that classification
- Frequent hospitalizations or office visits for acute exacerbations of HF - if occurring
- Complete operative report outlining operative approach used and all the components of the biventricular pacemaker insertion
- If applicable, the need for a pacemaker and an expectation that pacing is likely to occur much of the time
All documentation must be maintained in the patient's medical record and made available to the A/B MAC upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code(s) must describe the service performed. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient’s records and claims history.
For an upgrade from standard pacing to CRT, this A/B MAC would expect documentation narrative regarding the risk-benefit balance for that individual patient and his/her degree of HF, QRS duration/morphology, etc. A "stand-alone" upgrade in patients with an existing pacemaker or implanted cardiac defibrillator should be considered carefully and based on the individual patient’s unique circumstances.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the related LCD.
