Though the Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) System was introduced to reduce the complications with traditional ICD system with leads, this implant does carry risks such as infection and bleeding like every surgical procedure. If the S-ICD system procedures are performed at inpatient settings, the service of physicians and nurses will be available before and after surgery to address these risks, especially in complicated cases. However, the coding for inpatient S-ICD system procedures is entirely different from that of outpatient settings. ICD-9 procedure codes are used for reporting these procedures instead of CPT and additional codes are used depending on the payer to receive proper reimbursement.
ICD-9 CM Procedure Codes
Here are the ICD-9 procedure codes confirmed by the American Hospital Association (AHA) for reporting S-ICD System procedures.
- 37.20 – Non-invasive programmed electrical stimulation [NIPS]
- 37.70 – Initial insertion of lead (electrode), not otherwise specified
- 37.75 – Revision of lead (electrode)
- 37.77 – Removal of lead(s) (electrodes) without replacement
- 37.79 – Revision or relocation of cardiac device pocket
- 37.94 – Implantation or replacement of automatic cardioverter/defibrillator, total system (AICD) Includes implantation of defibrillator with leads (epicardial patches), formation of pocket (abdominal fascia), (subcutaneous) any transvenous leads, intraoperative procedures for evaluation of lead signals, and obtaining defibrillator threshold measurements (electrophysiologic studies [EPS])
- 37.95: Implantation of automatic cardioverter/defibrillator leads(s) only
- 37.96: Implantation of automatic cardioverter/defibrillator pulse generator only
- 37.97: Replacement of automatic cardioverter/defibrillator leads(s) only
- 37.98: Replacement of automatic cardioverter/defibrillator pulse generator only
- 89.49: Automatic implantable cardioverter/defibrillator (AICD) check –includes bedside check of an AICD or cardiac resynchronization defibrillator (CRT-D); checking pacing thresholds of device; interrogation only without arrhythmia induction
There is associated hospital inpatient MS-DRG (diagnosis-related groups) payment based on the documentation of relevant ICD-9 diagnosis coding and ICD-9 procedure coding combinations. Medicare provides reimbursement to the inpatient hospital services under the Inpatient Prospective Payment System (IPPS), which bases payment on MS-DRG. This payment system brings together similar diagnoses into a single payment level and gives reimbursement to the hospital based on the extent of resources typically required for treating patients having similar diagnoses and undergoing similar treatments. All services and supplies provided at the inpatient admission are bundled into a single MS-DRG reimbursement rate despite the length of patient stay, the intensity of treatments or the number of procedures performed for a particular individual. Thus, hospitals can bill their services with one global MS-DRG payment rate for each patient admission.
MS-DRG codes are assigned mainly according to the patient’s principle diagnosis and/or principal procedure performed. Here are the MS-DRG codes for S-ICD system procedures.
- MS – DRG 222: Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC
- MS – DRG 223: Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC
- MS – DRG 224: Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC
- MS – DRG 225: Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC
- MS – DRG 226: Cardiac defibrillator implant w/o cardiac cath w MCC
- MS – DRG 227: Cardiac defibrillator implant w/o cardiac cath w/o MCC
- MS – DRG 245: ICD generator procedures
- MS – DRG 265: ICD lead procedures
Need for Prior Authorization
In addition to these codes, prior authorization is required in the case of commercial insurance plans to receive reimbursement for the S-ICD System procedures. Prior-authorization allows physicians to submit a treatment plan before surgery which is reviewed by the insurer along with the patient’s insurance benefits and medical policy so as to ensure the treatment is covered and determine the applicable patient responsibility (coinsurance and/or copay, deductibles, and out-of-pocket amounts). Since the insurer will deny the claim if any discrepancies are found with patient’s insurance benefits, it is very important for surgeons to verify the insurance details of their patients before submitting a pre-authorization request.
Every insurer has their own requirements for prior authorization process. So, it is very important to contact the insurer and follow their requirements. Even so, prior authorization request typically includes patient information (name, date of birth, policy number), patient’s medical history details, description of current condition and treatment plan, letter of medical necessity (LOMN) describing the patient’s medical need, proposed procedure(s), medical device implanted and justification for treatment, proposed location of service (here, it is inpatient) and dates planned, summary of clinical evidence supporting the treatment plan such as comorbidities and copies of published literature that support the safety and effectiveness, description of the technology and justification for using it in the surgery, and a copy of the FDA approval letter.