June 13, 2007
The Heart Rhythm Society (HRS) prevailed in its objection to the National Correct Coding Initiative (NCCI), Version 13.3 edits scheduled to take effect on October 1, 2007 by convincing the Centers for Medicare & Medicaid Services (CMS) to defer action on implementation.
On April 29, 2007, HRS, along with the American College of Cardiology (ACC) and the Society of Thoracic Surgeons (STS), submitted a strong written objection to proposed edits that paired several procedures for removal of pacemaker pulse generator and/or electrodes (CPT codes 33233-33237) with services for removal of cardioverter-defibrillator pulse generator and/or electrodes (CPT codes 33241, 33243, 33244) without use of NCCI-associated modifiers which failed to recognize the necessary correlation of these services, particularly for high-risk patients in complex settings. The edits, had they been adopted, would have inappropriately denied payment for Column 2 codes when billed with Column 1 codes on the same date of service in the following table.
Column 1 Code Column 2 Code
33233 33241
33243, 33244 33233
33234 33241
33243, 33244 33235
33235 33241
33243, 33244 33235
33236 33241
33243, 33244 33236
33237 33241
33243, 33244 33237
These edits were suggested to CMS by a contractor medical director who observed improper coding of these services together. CMS agreed not to adopt the edits at this time, based on the comments received from HRS, ACC and STS.
Medically Unlikely Edits
In the fourth round of Medically Unlikely Edits (MUE) scheduled for implementation on October 1, 2007, CMS proposed to implement edits that would allow payment for only one unit of service for CPT codes 93724 through 93744 when billed for the same patient on the same date of service by the same provider.
In an appeal letter dated May 10, 2007, the Heart Rhythm Society expressed concern about the validity of the proposed edits and the impact the restrictions would place on standard of care and reimbursement. The edits, if implemented, would not only diminish the medical value of the services, they would also unfairly penalize electrophysiologists and result in reimbursement not commensurate with the time and costs for providing the services.
Clear examples were provided to demonstrate that the proposed edits are inconsistent with clinical judgment and sound medical practice, as there are circumstances where it is likely that more than one interrogation and potentially more than one programming session would occur on the same day for a hospitalized patient with an ICD receiving multiple therapies. There are also occasions when a patient is seen in the office and then again in the hospital after an intervention or treatment, and will require reprogramming/evaluation of their pacemaker, which occurs with complex and ill patients.
After review of our comments, CMS agreed to withdraw the proposed edits for one unit of service and recommend two MUEs for CPT codes 93724 through 93744.
If you have any questions regarding NCCI edits or MUEs, please contact Lisa Miller-Jones, Director of Reimbursement and Regulatory Affairs at 202-464-3433 or lmiller-jones@HRSonline.org.
