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MIR-2006-9AB, September 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Clarification Regarding Effective Dates for Carrier Claim Adjustments: Denied Replacement Defibrillator Claims Lacking a QR Modifier (MM5104)
Provider Types Affected
Providers who bill carriers for Automatic Implantable Cardiac Defibrillator (ICD) services rendered to Medicare beneficiaries
Provider Action Needed
Impact to You
If you have a claim for a replacement ICD that was denied solely because it lacked a QR modifier, you may request an adjustment for that claim for any date of service for which the replacement ICD was otherwise covered.
What You Need to Know
CR5104 clarifies CR4273 to establish that your carrier will consider any payable date of service when you seek an adjustment of a replacement ICD claim previously denied solely because it did not contain a QR modifier.
What You Need to Do
Make sure that your billing staff are aware that they can seek an adjustment for your replacement ICD claim denied due to lack of the QR modifier for any date of service for which the claim would otherwise have been payable.
Background
CR3604 (Transmittal 497), effective January 27, 2005, gave CMS carriers instructions on how to process Automatic Implantable Cardiac Defibrillator (ICD) claims for services provided under expanded coverage for new indications. One of these instructions was the requirement that the patient be enrolled in a data collection system.
Such patient enrollment is noted on the claim by the QR modifier, which identifies services being covered under a clinical study, and is required as a condition for payment on claims for ICD services rendered as:
- Part of the new indications (effective on January 27, 2005); or
- For any other ICD services rendered as a primary prevention of cardiac arrest (i.e., no history of induced or spontaneous arrhythmias).
To identify these instances, Centers for Medicare & Medicaid Services (CMS) systems maintainers created an edit to check the diagnosis code on the claim. If the diagnosis code was not a secondary prevention diagnosis code, then the QR modifier was required in order to cover the services.
Carriers turned on this edit, effective April 1, 2005. In order to ensure that the QR modifier was being applied to the extent possible to claims for ICD services rendered for the primary prevention of cardiac arrest, carriers were instructed to turn on the original edit such that claims with dates of service prior to April 1, 2005 would also be checked for this modifier, as appropriate.
Note: When any of the secondary prevention diagnosis codes appear on an ICD claim, the QR modifier is not required. However, you can append the QR modifier for secondary prevention diagnoses when it is appropriate, i.e., when the data is submitted to a data collection registry. |
After the publication of CR3604, CMS became aware of additional possible diagnoses which show neither primary nor secondary prevention of cardiac arrest, for example, when the ICD is replaced due to ICD recall or device complication (such as the end of battery-life).
Since claims such as these should not be denied because they lack a QR modifier, on January 27, 2006, CMS issued CR4273 (Transmittal 819). CR4273 added two new ICD-9-CM diagnosis codes to the list of those that do not require a QR modifier and which do not, by themselves, represent a condition where primary or secondary prevention can be ascertained:
- 996.04 , Mechanical complication of cardiac device, implant, and graft, due to automatic implantable cardiac defibrillator; and
- V53.32 , Fitting and adjustment of other device, automatic implantable cardiac defibrillator.
To ensure that replacement ICD claims are not erroneously denied for a lack of QR modifier, the new edit accompanying CR4273 affects claims with dates of service on and after April 1, 2005. However, because the original carrier edit considered all dates of services as it checked for a QR modifier, including dates prior to April 1, 2005, it is possible that there will be replacement ICD claims erroneously denied with dates of service prior to April 1, 2005.
For this reason, when this issue is brought to their attention, Medicare carriers are to consider for possible adjustment all payable dates of service for replacement ICD claims when these claims have been denied solely for the lack of a QR modifier.
CR5104, from which this article is taken, makes this clarification and instructs carriers to inform you that you may have had claims for replacement ICDs erroneously denied for lack of a QR modifier and requiring such an adjustment. Be aware, however, that the carriers do not have to search their files to retroactively pay claims, nor does this instruction apply to claims submitted to fiscal intermediaries (FIs), who implemented the original and revised edits according to dates of service.
Additional Information
You can find more information about the effective dates for carrier claim adjustments for replacement ICD claims denied because they lacked a QR modifier by going to CR5104, which is available at http://www.cms.hhs.gov/Transmittals/downloads/R971CP.pdf  o n the CMS Web site.
Additionally, more information about ICD claims may be found in MLN Matters articles MM3604 and MM4273, which you can find at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3604.pdf a nd http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4273.pdf , respectively.
If you have any questions, please contact your carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5104
Pub. 100-4, Transmittal# R971CP, CR# 5104
Related CR Release Date: June 2, 2006
Effective Date: April 1, 2005
Implementation Date: September 5, 2006
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