Professional claims
Effective for claims with dates of service on or after August 13, 2013, MACs shall pay for implanted permanent cardiac pacemakers, single chamber or dual chamber, for one of the following procedure codes if the claim contains at least one of the designated diagnosis codes in addition to the –KX modifier:
•33206 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial;
•33207 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – ventricular; or
•33208 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial and ventricular.
Institutional claims
Effective for claims with dates of service on or after August 13, 2013, MACs shall pay for implanted permanent cardiac pacemakers, single chamber or dual chamber, for the following HCPCS codes if the claim contains at least one of the designated Procedure codes, and at least one of the designated diagnosis codes, in addition to the –KX modifier:
•C1785 – Pacemaker, dual chamber, rate-responsive (implantable);
•C1786 – Pacemaker, single chamber, rate-responsive (implantable);
•C2619 – Pacemaker, dual chamber, nonrate-responsive (implantable);
•C2620 – Pacemaker, single chamber, nonrate-responsive (implantable);
•33206 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial
•33207 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – ventricular
•33208 – Insertion or replacement of permanent pacemaker with transvenous electrode(s) – atrial and ventricular
MACs have discretion to cover or not cover the following Procedure codes:
•33227 – Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; single lead system; or
•33228 – Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system.
Cardiac Pacemaker Non-covered ICD-ICD-10 Diagnosis Code
For claims with dates of service on or after implementation of ICD-10, for implanted permanent cardiac pacemakers, single chamber or dual chamber, using one of the following HCPCS and/or Procedure codes: C1785, C1786, C2619, C2620, 33206, 33207, or 33208, ICD-10 diagnosis code R55 is not covered even if the claim contains one of the valid diagnosis codes listed above.
MACs will use the following messages when denying claims for implanted permanent cardiac pacemakers, single chamber or dual chamber, containing one of the following HCPCS and/or Procedure codes: C1785, C1786, C2619, C2620, 33206, 33207, or 33208, and ICD-10 diagnosis code R55 with the following messages:
•CARC 96: Non-covered charge(s).
•RARC N569: Not covered when performed for the reported diagnosis.
•Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed Advance Beneficiary Notice (ABN) is on file.
•Group Code PR assigning financial liability to the beneficiary, if a claim is received with occurrence
