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Reimbursement for 33249 in primary prevention situations

Amy Posted Thu 17th of March, 2016 09:01:03 AM

I am in Michigan and having a big problem getting paid by Medicare Blue (Medicare Advantage plan) for primary prevention ICDs (CPT 33249). We are following Medicare NCD 20.4 and billing 33249 (plus 33225 for Bi-V when applicable) using I25.5 for ischemic cardiomyopathy or I42.0 for non-ischemic dilated cardiomyopathy. I have received conflicting information about WHO is responsible to pay when the Q0 modifier is used on these claims. Some tell me that original Medicare should be billed when Q0 is used (and I have had SOME claims pay). Some tell me that the advantage plan should be billed. I have had SOME claims paid by the advantage plan, but by billing the claim WITHOUT the Q0. Other claims billed to the advantage plan EXACTLY the same way, have denied that they don;t meet NCD 20.4. Similar situation when billing original Medicare for these advantage plan patients, when billed with Q0, SOME pay, some reject stating that the correct payer should be billed. I am at a loss because there seems to be no rhyme or reason for any of these and I can't get a clear answer.

SuperCoder Answered Fri 18th of March, 2016 08:58:28 AM

the appropriate usage of QO modifier is when a service is performed as part of an approved clinical research study and when it is investigative in nature.
In the above scenario 33249 without a Q0 will deny for MCR(not MCR replacement) patients for whom a Dx of 425.4 or 414.8 is the indication, without an arrythmia such as v tach or whatever being documented. Also, you would not use it for patients where V12.53 is appropriate. It is a modifier used to indicate an ICD was placed for primary prevention of sudden cardiac death. The patients are merely entered into a clinical research database...the patients themselves are not being "researched".
In other words, if they have cardiomyopathy (ischemic or non-ischemic) and no arrhythmia such as v-tach, and they have never had a cardiopulmonary arrest with successful resuscitation, they are considered 'at risk' for sudden cardiac death.

To show this, MCR requires the Q0 in order for the patient to be followed by being entered into a registry to monitor whether the ICD implant was successful in preventing this severe form of arrhythmia and sudden death. It is only for MCR, not MCR replacements, and any claim without the modifier but with the required diagnosis will be denied.

Hope this helps!

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