Cardiovascular Implant Device Monitoring Services

Reimbursement Policy:
Cardiovascular Implant Device Monitoring Services

Effective Date:
February 25, 2019

Purpose:
Provide guidelines on cardiovascular implant device monitoring services when appropriately billed by professional providers

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
According to CMS policy, when a cardioverter-defibrillator analysis (93260-93261, 93282-93284, 93289, 93292 or 93295) is performed for monitoring purposes only, in the absence of symptoms or discharge of the device, it is expected that the service be performed no more than once every three months. Therefore, when 93260-93261, 93282-93284, 93289, 93292 or 93295 is billed and the diagnosis reported is ICD-10 code Z95.810 (Presence of automatic [implantable] cardiac defibrillator), only one monitoring service will be allowed within a three month period.

Performance of these services at greater frequencies as described above is not typically required in virtually all clinical circumstances, and this policy conforms with industry norms.

The CPT® codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall deny 93260-93261, 93282-93284, 93289, 93292 or 93295 (Automatic implantable cardiac defibrillator [AICD] monitoring) billed greater than once per three months when the diagnosis is ICD-10 code Z95.810 (Presence of automatic [implantable] cardiac defibrillator).

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In denied instances where the provider is participating, no member liability shall be applied.

In denied instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
11/15/2017: Policy approved

CPT® is a registered trademark of the American Medical Association.

Policy 116_v1.0_11152017