The most recent Centers for Medicare and Medicaid Services and the National Coverage Determination for Cardiac Pacemakers (20.8.3) is looking for a direct correlation between a patient’s symptoms and an irreversible conduction disorder. The principle conduction defects that are covered include complete heart block, second-degree Mobitz type II heart block, other second-degree AV block, sinus node dysfunction, and congenital complete heart block. Please check http://www.cms.gov for the most recent version of National Coverage Determination for Cardiac Pacemakers for acceptable billing indications. The most recent National Coverage Determination is requesting that a KX modifier be submitted with the bill attesting to the fact that the patient must have a nonreversible symptomatic bradycardia and documented, directly correlated symptoms such as syncope, seizures, dizziness, confusion, and/or congestive heart failure. This modifier may make it easier for the government to pull pacemaker records and examine the supporting documentation for the KX modifier.
To date there is no evidence of any pending audit related to the new National Coverage Determination and the KX modifier. That being said, it is the author’s suspicion that an audit may occur in the future. This is based on the previous Department of Justice audit of National Coverage Determination for Implantable Automatic Defibrillators, as well as the ease of running reports with respect to acceptable pacemaker indications and the KX modifier. It is the author’s strong advice that each operator should remain vigilant with respect to their medical record documentation and appropriate billing for each implant procedure.