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Claim Payment Policy

Title:Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)

Policy #:03.02.13b


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.


Intent
The intent of this policy is to communicate the claims processing results for evaluation or setup of a cardiac pacemaker reported with an electrocardiogram (ECG/EKG) when performed on the same date of service, by the same provider, on the same claim form.

Description
A cardiac pacemaker is a self-contained, battery-operated unit that sends electrical stimulation to the heart to normalize cardiac rhythm. Pacemaker evaluation may include an assessment of the rate, pulse amplitude and duration, configuration of waveform, and/or sensory function of the pacemaker, as well as telephonic analysis, electrocardiograms, and the physician's interpretation of the findings.

An electrocardiogram (ECG/EKG) is a test that records the electrical activity of the heart. It measures the rate and regularity of heartbeats, as well as the size and position of the chambers, the presence of any heart damage, and the effects of any drugs or devices used to regulate the heart (eg, pacemaker).

Policy
When an evaluation or setup of a cardiac pacemaker is reported with an electrocardiogram (ECG/EKG), the ECG/EKG is considered to be integral or inherent to the pacemaker evaluation and is, therefore, not eligible for reimbursement consideration.

Guidelines
This claim payment rationale applies only to the applicable code combinations addressed in this policy and does not apply to any other code and/or code and modifier combinations. Claims are processed according to the statements in this policy. When a medical policy on this topic also exists, the medical necessity criteria listed in the medical policy must be met.

The table below depicts the claims processing outcome when a cardiac pacemaker evaluation or setup code (column 1) is reported with an electrocardiographic (ECG/EKG) code (column 2). This table is a complete list of applicable codes.


WHEN ANY OF THE CODES IN COLUMN 1 ARE REPORTED WITH ANY OF THE CODES IN COLUMN 2, THE CODES IN COLUMN 1 ARE ELIGIBLE FOR REIMBURSEMENT CONSIDERATION AND THE CODES IN COLUMN 2 ARE DENIED
COLUMN 1

CARDIAC PACEMAKER EVALUATION OR SETUP PROCEDURE CODES
COLUMN 2

ECG/EKG PROCEDURE CODES
OUTCOME
93279, 93280, 93281, 93282, 93283, 93284, 93286, 93287, 93288, 93289, 93293, 93294, 93295, 93296, 93640, 93641, 93642, 93724, 9374593000, 93005, 93010, 93040, 93041, 9304293279, 93280, 93281, 93282, 93283, 93284, 93286, 93287, 93288, 93289, 93293, 93294, 93295, 93296, 93640, 93641, 93642, 93724, 93745 are processed as eligible for reimbursement consideration.

93000, 93005, 93010, 93040, 93041, 93042 are denied for
reimbursement consideration as inherent to the pacemaker evaluation or setup.

The inclusion of codes in this policy does not imply coverage or reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply

MEDICARE

This policy is consistent with Medicare Correct Coding Initiative (CCI) edits.

References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.8.1: Cardiac pacemaker evaluation services. [CMS Web site]. 10/01/84. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20.8.1&ncd_version=1&basket=ncd%3A20%2E8%2E1%3A1%3ACardiac+Pacemaker+Evaluation+Services. Accessed January 30, 2009.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.15: Electrocardiographic (EKG) services. [CMS Web site ]. 08/26/04. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20.15&ncd_version=2&basket=ncd%3A20%2E15%3A2%3AElectrocardiographic+%28EKG%29+Services. Accessed January 30, 2009.

Highmark Medicare Services. Local Coverage Determination (LCD).L27533: Surveillance of implantable cardioverter-defibrillator (ICD), office, Internet or non-Internet based. [Highmark Medicare Services Web site]. Original: 07/11/08. (Revised: 12/12/08). Available at: http://www.highmarkmedicareservices.com/policy/mac-ab/l27533-r4.html. Accessed January 30, 2009.

National Institutes of Health. Medical Encyclopedia. Pacemaker. [MedlinePlus Web site]. 05/15/08. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/007070.htm. Accessed January 30, 2009.

US Food and Drug Administration (FDA). FDA Heart Health Online. Cardiac pacemaker (implanted). [FDA Web site]. 02/27/04. Available at: http://www.fda.gov/hearthealth/treatments/medicaldevices/cardiacpacemakerimplanted.html. Accessed January 30, 2009.
Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code SystemCode Number(s) and Narrative(s)
CPTTO REPORT ELECTROCARDIOGRAM (ECG/EKG), USE THE FOLLOWING CODES: 93000, 93005, 93010, 93040, 93041, 93042

TO REPORT PACEMAKER EVALUATION OR SETUP, USE THE FOLLOWING CODES: 93279, 93280, 93281, 93282, 93283, 93284, 93286, 93287, 93288, 93289, 93293, 93294, 93295, 93296, 93640, 93641, 93642, 93724, 93745
ICD ProcedureN/A
ICD DiagnosisN/A
HCPCS Level IIN/A
Revenue CodesN/A





      Version Effective Date: 01/01/2009
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      The Policy Bulletins on this web site were developed to assist AmeriHealth and its subsidiaries ("AmeriHealth") in administering the provisions of the respective benefit programs, and do not constitute a contract. If you are an AmeriHealth member, please refer to your specific benefit program for the terms, conditions, limitations and exclusions of your coverage. AmeriHealth does not provide health care services, medical advice or treatment, or guarantee the outcome or results of any medical services/treatments. The facility and professional providers are responsible for providing medical advice and treatment. Facility and professional providers are independent contractors and are not employees or agents of AmeriHealth. If you have a specific medical condition, please consult with your doctor. AmeriHealth reserves the right at any time to change or update its Policy Bulletins. ©2012 AmeriHealth, Inc. All Rights Reserved.  Current Procedural Terminology ©2012 American Medical Association. All Rights Reserved.
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