Issue 2006-03, March 2006

Modification to QR Modifier Edit for Automatic Implantable Cardiac Defibrillator (ICD) Services

Provider Types Affected
Providers who bill carriers or fiscal intermediaries for ICD services rendered to Medicare beneficiaries

Provider Action Needed

Impact to You
The QR modifier is not required to process claims with ICD-9-CM codes 996.04 (Mechanical complication of cardiac device, implant, and graft, due to automatic implantable cardiac defibrillator) or for V53.32 (Fitting and adjustment of other device, automatic implantable cardiac defibrillator) for ICD services with dates of service on or after April 1, 2005. The QR modifier should continue to be used on all claims for ICD device implants when the beneficiary is enrolled in a data collection system such as a registry.

What You Need to Know
The QR modifier is required on claims for primary prevention ICD device implantations. The QR signifies that data is being reported on the patient and data reporting is a requirement of primary prevention device insertion. However, claims submitted for replacement devices do not carry the patient’s previous arrhythmic diagnoses; therefore, these claims look like claims for primary prevention clinical indications. CR4273, from which this article is taken, adds two new ICD-9-CM codes, addressing ICD replacement due to instrument recall or device complication, to the list of codes that do not require the use of the QR modifier for claims processing. These codes are effective on April 1, 2006, for claims with dates of service on and after April 1, 2005.

What You Need to Do
Make sure that your billing staffs continue to bill ICD implantation and replacement services appropriately according to professional coding guidelines. If claims with dates of service on or after April 1, 2005 were inappropriately denied, they should be brought to the attention of the local Medicare contractor.

Background
The QR modifier identifies services that are being covered under a clinical study (e.g., patients enrolled in a registry), and effective January 27, 2005, is required as a condition for payment on claims for ICD services rendered in the primary prevention of cardiac arrest.

CR3604, Transmittal 497 (released March 8, 2005), provides guidance for the coverage of ICD services under newly expanded coverage. One of the requirements for covering the new ICD indications (effective January 27, 2005) is that the patient be enrolled in a data collection system as indicated by the presence of the QR modifier on the claim, which identifies services being covered under a clinical study.

Again, the modifier is used to identify patients who meet the coverage requirement for any indication that is for the primary prevention of sudden cardiac arrest (i.e., no history of induced or spontaneous arrhythmias). It is not required for ICD services rendered for the secondary prevention of cardiac arrest as documented by the secondary prevention diagnosis codes noted in the table below. (Note, however, that you can use the QR modifier for secondary prevention diagnoses if you deem it to be appropriate, i.e., in order to report the data to the data collection system, when this reporting applies).

Two New Diagnosis Codes Added
Since CR3604 was published, the Centers for Medicare & Medicaid Services (CMS) has become aware that there are other clinical situations for ICD services in which the diagnoses show neither primary nor secondary prevention of cardiac arrest. Such a situation could occur when the patient is having his/her ICD replaced, perhaps due to ICD recall, or to a device complication (such as the end of battery-life).

Since it would be incorrect to deny such claims because they lacked the QR modifier, in CR4273, CMS is adding two new ICD-9-CM diagnosis codes to the list of those that do not require it:

• Mechanical complication of cardiac device, implant, and graft; due to automatic implantable cardiac defibrillator

Use this diagnosis code when the patient is having his/her ICD replaced due to a mechanical complication, as could occur due to ICD recall.

V53.32 Fitting and adjustment of other device; automatic implantable cardiac defibrillator

Use this diagnosis code when there is a fitting or an adjustment, including device removal or replacement; it would be used when the ICD reaches its natural end-of-battery life.

The table below displays the new list of diagnoses that do not require a QR modifier for ICD services in order to be paid (both those indicating the secondary prevention of cardiac arrest, and ICD replacement).

Remember: Carriers and FIs will adjust, as appropriate, claims brought to their attention (with dates for service on or after April 1, 2005), that were denied because the diagnosis code was 996.04 or V53.32, and lacked a QR modifier.

Additional Information
More information about the use of the QR Modifier for Automatic Implantable Cardiac Defibrillator (ICD) Services is available in the official instruction (CR4723) issued to your carrier/intermediary. That instruction is available at http://www.cms.hhs.gov/Transmittals/downloads/R819CP.pdf on the CMS Web site. Another good source for additional information is Medlearn Matters article MM3604, at http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/mm3604.pdf on the CMS Web site.

Finally, if you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf 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.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles

Pub. 100-4, Transmittal# R819CP, CR# 4273
Medlearn Matters Number: MM4273
Related CR Release Date: January 27, 2006
Effective Date: April 1, 2005
Implementation Date: April 3, 2006