Novitas Solutions, in collaboration with CMS (Centers for Medicare & Medicaid Services), continues to focus on lowering the CERT (Comprehensive Error Rate Testing) claims paid error rate. Currently, one area of concern identified in the CERT data is DRG (Diagnosis Related Group) 227, Cardiac Defibrillator Implant without Cardiac Catheterization without Major Complication or Co-morbiditiy.
CMS defines an implantable cardiac defibrillator as "an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating." The CMS National Coverage Determination Guidelines describe the covered indications for implantation of a cardiac defibrillator. There are two categories for these indications:
For the full list of CMS covered indications, please refer to the CMS IOM (Internet Only Manual), National Coverage Determinations, Publication 100-03, Part 1, Section 20.4.
For guidance on the implantation of a single or dual chamber pacemaker, you can refer to the NCD (National Coverage Determination) for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (20.8.3) implemented 07.06.15.or 20.8 for previous dates of service.
According to the CMS guidelines (IOM 100-08, Chapter 6, section 6.5.4)
When reviewing submitted medical record documentation for these services, the clinical reviewer often finds that the implantable cardiac defibrillator procedure is a planned procedure, the beneficiary is admitted to the hospital, the procedure is performed, there are no intra- or post-operative complications, and the beneficiary goes home in one to two days. In these situations, the documentation supports that the admission is for the sole purpose of performing a non-covered procedure, and the beneficiary never developed a need for a covered level of service (the inpatient hospital stay), therefore; the admission is denied.
When reviewing documentation for DRG 227, the clinical reviewer is initially looking for documentation to support a CMS covered indication for the procedure. It is important that the documentation clearly supports the provider's decision to implant a cardiac device. If the coverage indications are met, since this procedure is not on the CMS Inpatient Only Procedure list, the reviewer is next looking for documentation of severity of illness and intensity of service to support an inpatient hospital stay for this procedure.
The provider needs to be sure that an inpatient admission is the most appropriate level of care following the CMS guidelines above. Observation care should be utilized until it is determined that the patient can either be discharged or that an inpatient admission is warranted. It is imperative that there is a continued focus on lowering the CERT error rate and physician/facility involvement is a key component to this goal.
For additional guidance in making the decisions for appropriate patient status/level of care, please review the following bulletins, available on our website:
CMS offers additional guidance for determining the appropriate level of care. “Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. It is important to remember that Inpatient and Observation levels of care are patient statuses and not necessarily locations within the facility.
If you receive a request from the CERT contractor or Novitas Solutions for documentation to support an implantable cardiac defibrillator, be sure to send the hospital record, including:
Additional information on inpatient hospital services and implantable cardiac defibrillators is located in the Centers for Medicare and Medicaid Services Benefit Policy Manual, Publication 100-02, Chapter 1 and CMS Program Integrity Manual, Publication 100-08, Chapter 6, Section 6.5.4.
You can also find additional information on inpatient hospital services in our Local Coverage Article, Acute Care Inpatient, Observation and Treatment Room Services, A52985 (JH) (JL).