Mountain State Medical Policy Bulletin

Section: Miscellaneous
Number: G-14
Topic: Pacemakers and Associated Services/Procedures
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

Temporary Pacemakers

A temporary pacemaker is inserted for reasons such as:

  1. As an emergency procedure when medication is ineffective
  2. While awaiting a permanent pacemaker
  3. As a temporary measure to determine whether the patient's heart will return to normal state

Medical indications for the insertion of a temporary pacemaker include the following:

  • Symptomatic bradycardia (427.81-427.89) or heart block (426-426.6, 426.9)
  • Acute anterior wall MI (410.0-410.12) with a right bundle branch block (426.4) and left anterior hemiblock (426.2)
  • Overdrive pacing for resistant ventricular tachycardia

Payment may be made to the same doctor or to different doctors for consultation or medical treatment for the heart condition and the insertion of a temporary pacemaker.

When a temporary pacemaker is inserted during diagnostic or therapeutic cardiac procedures, payment may be made for the temporary pacemaker only when it is the highest paying procedure.

However, when a temporary pacemaker is inserted in conjunction with left cardiac catheterization, the claim should be processed under code 93799.

Claims reporting the insertion of a temporary pacemaker performed in conjunction with a right heart catheterization should be given individual consideration.

Permanent Pacemaker

Indications for the insertion of a permanent pacemaker include the following:

  • The patient has complete atrioventricular block lasting more than 3 weeks following an acute myocardial infarction or persistent A-V block following cardiac surgery.
  • Advanced second degree block
  • Symptomatic sinus bradycardia without A-V block
  • Symptomatic bilateral bundle branch block/trifascicular block
  • Symptomatic sinus arrest, sick sinus syndrome, sinoatrial block
  • Symptomatic incomplete A-V block (mobitz type I) (426.13)

When a surgeon submits a claim for insertion of a permanent pacemaker, and medical care, only the insertion of the pacemaker should be paid. If unusual circumstances or complications arise, the claim should be processed in accordance with the guidelines set forth in Medical Policy Bulletin V-28 (Inpatient Preoperative Care).

When one doctor inserts the permanent pacemaker and another doctor provides the medical care, follow the guidelines issued in Medical Policy Bulletin V-2 (Concurrent Care).

Insertion of an Atrio-Ventricular Sequential Pacemaker or a Universal Pacemaker involves the additional placement of an electrode in the atrium as well as the ventricle. Claims requesting payment for either of these services should be processed under code 33208.

If the surgeon reports the insertion of a permanent pacemaker (epicardial, transvenous, A-V sequential or universal) and electrodes in conjunction with open heart surgery, payment should be made in accordance with the guidelines for multiple surgical procedures in Medical Policy Bulletin S-100.

NOTE:
Also see Medical Policy Bulletin S-44 (Implantation of a Permanent Pacemaker by One or Two Physicians).

Transcutaneous Pacer Application

Transcutaneous pacemaker application is considered an integral part of a doctor's medical care. It is not eligible as a distinct and separate service when performed with medical care. If the transcutaneous pacemaker application is reported on the same day as medical care, and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same date of service includes the allowance for the transcutaneous pacemaker application. A participating, preferred, or network provider cannot bill the member separately for the transcutaneous pacemaker application in this case.

If the transcutaneous pacemaker application is performed independently, process it under code 92953.

Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the transcutaneous pacemaker application. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.

Description

The artificial cardiac pacemaker is a device designed to electronically stimulate the heart in a specific sequence that enables it to contract. This device is used primarily when the heart's own intrinsic pacemaker, the sinoatrial node, fails due to various disease conditions. There are three different types of pacemakers categorized by how they are applied: temporary pacemakers, transcutaneous pacer application, and permanent pacemakers.

Permanent Pacemaker

When a normal heart function cannot be restored, a permanent pacemaker is inserted for the persistent conduction defect.

Transcutaneous Pacer Application

Transcutaneous pacing is a non-invasive procedure that involves the application of electrodes to the chest wall of the patient. Electrical current is then delivered via the electrodes to achieve pacing. This procedure may be performed as an emergency alternative to temporary pacemaker insertion.

Procedure Codes

332003320133206332073320833210
332113321233213332143321633217
332183322033222332233323333234
332353323633237332383324033241
332433324433245332463324992953

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.