Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac
Pacemakers

**Abstract:**  
The National Coverage Determination (NCD) 20.8.3, Single Chamber and Dual
Chamber Permanent Cardiac Pacemakers, was revised with an effective date of
August 13, 2013. The CMS A/B Medicare Administrative Contractors (MACs) have
been instructed to implement the NCD at the local level. The following
provides coding and billing instructions for the implementation of NCD 20.8.3.
(CMS policy language is in _italics_.) The NCD "Item/Service Description" and
"Indications and Limitations" are repeated here.  
  
 **Item/Service Description** _ _ **  
  
**__**A. General** _ _  
Permanent cardiac pacemakers refer to a group of self-contained, battery
operated, implanted devices that send electrical stimulation to the heart
through one or more implanted leads. They are often classified by the number
of chambers of the heart that the devices stimulate (pulse or depolarize).
Single chamber pacemakers typically target either the right atrium or right
ventricle. Dual chamber pacemakers stimulate both the right atrium and the
right ventricle.  
  
The implantation procedure is typically performed under local anesthesia and
requires only a brief hospitalization. A catheter is inserted into the chest
and the pacemaker's leads are threaded through the catheter to the appropriate
chamber(s) of the heart. The surgeon then makes a small "pocket" in the pad of
the flesh under the skin on the upper portion of the chest wall to hold the
power source. The pocket is then closed with stitches.  
  
The Centers for Medicare & Medicaid Services (CMS) has determined that the
evidence is sufficient to conclude that implanted permanent cardiac
pacemakers, single chamber or dual chamber, are reasonable and necessary for
the treatment of non-reversible symptomatic bradycardia due to sinus node
dysfunction and second and/or third degree atrioventricular block. Symptoms of
bradycardia are symptoms that can be directly attributable to a heart rate
less than 60 beats per minute (for example: syncope, seizures, congestive
heart failure, dizziness, or confusion).  
  
__ **Indications and Limitations of Coverage  
  
B. Nationally Covered Indications** _ _  
The following indications are covered for implanted permanent single chamber
or dual chamber cardiac pacemakers:__

  1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and
  2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.

**C. Nationally Non-Covered Indications** _ _  
The following indications are non-covered for implanted permanent single
chamber or dual chamber cardiac pacemakers:__

  1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,
  2. Asymptomatic first degree atrioventricular block,
  3. Asymptomatic sinus bradycardia,
  4. Asymptomatic sino-atrial block or asymptomatic sinus arrest,
  5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,
  6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),
  7. Syncope of undetermined cause,
  8. Bradycardia during sleep,
  9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,
  10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,
  11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and
  12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.

**D. Other** _  
Medicare Administrative Contractors will determine coverage under section
1862(a)(1)(A) of the Social Security Act for any other indications for the
implantation and use of single chamber or dual chamber cardiac pacemakers that
are not specifically addressed in this national coverage determination.  
(This NCD last reviewed August 2013.)_  
  
 **Please note:** The "Decision Memo for Cardiac Pacemakers: Single-Chamber
and Dual-Chamber Permanent Cardiac Pacemaker (CAG-00063R3)" states:  
  
 _CMS initiated this current national coverage analysis to reconsider coverage
indications for single chamber and dual chamber cardiac pacemakers. The scope
of this reconsideration and this decision memorandum does not address
biventricular pacemakers, pacemakers that stimulate more than two heart
chambers, those devices used to treat tachyarrhythmias and cardiac
dyssynchrony, cardiac resynchronization therapy, cardiac pacemaker evaluation
services, or self-contained pacemaker monitors.  
  
Medicare Administrative Contractors will determine coverage under section
1862(a)(1)(A) of the Social Security Act for any other indications for the
implantation and use of single chamber or dual chamber cardiac pacemakers that
are not specifically addressed in this national coverage determination._  
  
The coding and billing guidelines only apply to those CPT codes for the
initial insertion of cardiac pacemakers:

  * 33206 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial
  * 33207 ventricular
  * 33208 atrial and ventricular

The NCD does not address replacement of pacemaker generators. CPT codes 33227,
33228 and 33229 or 33233 are therefore not addressed in this coding article.  
  
 **CMS NCD Covered Conditions and Diagnosis Codes - Group I  
  
Clinical Conditions:**

  * Documented non-reversible symptomatic bradycardia due to sinus node dysfunction
  * Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block

**Diagnosis Codes (ICD-10-CM) (Attest with Modifier - KX):**

  * Atrioventricular (AV) block (I44.2)
  * Mobitz (type II) AV block (I44.1)
  * Other second degree AV block (I44.1)
  * Sinoatrial node dysfunction/Sick sinus syndrome (I49.5)
  * Congenital heart block (Q24.6)

**Contractor (Additional) Diagnosis Codes (ICD-10-CM) Allowed by the NCD -
Group II (Attest with Modifier - KX)**

  * Atrioventricular block, unspecified (Symptomatic) (I44.30)
  * First-degree atrioventricular block (Symptomatic with PR interval more than 300 milliseconds) (I44.0)
  * Left bundle branch block, other or unspecified (I44.7)
  * Right bundle branch block, unspecified or other (I45.10 / I45.19)
  * Bundle branch block, unspecified (I45.10 or I45.19)
  * Right bundle branch block and left posterior fascicular block (I45.2)
  * Right bundle branch block and left anterior fascicular block (I45.2)  
o Other bilateral bundle branch block (I45.2)  
o Bifascicular block (I45.2)  
o Trifascicular block (I45.3)

  * Supraventricular tachycardias in which a pacemaker is specifically for control of the tachycardia (I47.1 or I47.9)
  * Paroxysmal supraventricular tachycardia/supraventricular tachycardia (SVT that is reproducibly terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects) (I47.1/I47.9)
  * Atrial fibrillation/atrial fibrillation, persistent; unspecified atrial fibrillation (I48.11/I48.19/I48.91) with symptomatic bradycardia due to necessary medical therapy
  * Atrial flutter/atrial flutter, typical/atypical/unspecified (I48.3/I48.4 /or I48.92 with symptomatic bradycardia due to necessary medical therapy
  * Hypersensitive carotid sinus syndrome and neurocardiogenic syncope (Syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer or for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing (G90.01)

**Other Conditions Not Addressed by the NCD or by the Contractor - Group III
include but are not limited to the following (Attest with Modifier - SC):**

  * Cardiac resynchronization therapy
  * Obstructive hypertrophic cardiomyopathy
  * Pacing in children, adolescents, and patients with congenital heart disease
  * Pacemaker or generator replacements
  * Sustained pause-dependent ventricular tachycardia, with or without QT prolongation

**Modifier Usage:**  
Modifier - KX (Requirements specified in the medical policy have been met)
must be used as an attestation by the practitioner and/or provider of the
service that documentation is on file verifying the patient has a symptomatic
arrhythmia or a high potential for progression of the rhythm disturbance
requiring a permanent pacemaker for **Groups I and II**. Bradycardia that is
the consequence of essential long-term drug therapy of a type and dose for
which there is no acceptable alternative **does not exclude** the use of
modifier - KX.  
  
In addition, use of modifier - KX may be used in patients without symptoms in
Groups I and II in the following situations:

  * Awake, symptom-free patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds or any escape rate less than 40 beats per minute (bpm), or with an escape rhythm that is below the AV node
  * Awake, symptom-free patients with atrial fibrillation and bradycardia with one or more pauses of at least 5 seconds or longer
  * Catheter ablation of the AV junction
  * Postoperative AV block that is not expected to resolve after cardiac surgery
  * Patients with neuromuscular diseases, e.g., myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy, and peroneal muscular atrophy, with third-degree and advanced second-degree AV block at any anatomic level
  * Asymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or LV dysfunction is present or if the site of block is below the AV node
  * Second or third-degree AV block during exercise in the absence of myocardial ischemia
  * Persistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegaly
  * Asymptomatic second-degree AV block at intra-or infra-His levels found at electrophysiological study
  * First- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromise
  * Asymptomatic type II second-degree AV block with a narrow QRS. Second-degree AV block with a wide QRS including isolated right bundle-branch block

For medically necessary pacemaker insertion in conditions not addressed by the
NCD or this article, **Group III** , use **modifier - SC** (Medically
necessary service or supply).  
  
 **Modifiers -GA and -GZ:**

Modifier -GA (Waiver of liability statement issued as required by payer
policy, individual case) should be used when the provider wants to indicate
that he/she anticipates that Medicare will deny a specific service as not
reasonable and necessary and an Advanced Beneficiary Notice (ABN) Form
CMS-R-131 has been signed by the beneficiary and is on file. Modifier -GA may
also be used on assigned claims when a patient refuses to sign the ABN and the
latter is properly witnessed. For claims submitted to the Part A MAC,
occurrence code 32 and the date of the ABN are required.

Modifier -GZ should be used when the provider wants to indicate that it is
expected that Medicare will deny the specific services as not reasonable and
necessary and the beneficiary was not asked to sign an ABN.

Claims for pacemaker claims that do not meet the criteria for modifier -KX or
-SC should have modifier -GA or -GZ appended depending on the ABN status and
will be denied.

**Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. 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.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.