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Avoid pacemaker claim denials

29 May 2016

By: Catherine Trevis, clinical documentation specialist

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With the implementation of ICD 10 came many new coding rules. One notable change comes with the coding of syncope with a pacemaker insertion. According to the new Medicare guidelines, all implanted permanent single chamber or dual chamber cardiac pacemaker claims will be DENIED if the diagnosis of R55 (syncope) appears on the claim, even if it appears with a payable diagnosis (such as sick sinus syndrome or symptomatic bradycardia). This is true of both inpatient and outpatient procedures.

If a diagnosis of syncope is documented, and specifically tied to another diagnosis (i.e. syncope d/t sick sinus syndrome), then syncope is considered a symptom code and will not be coded as part of the bill, thus avoiding the denial. If the diagnosis of syncope is documented as a stand-alone diagnosis, the CDI or coder will need to query the MD to try to connect the symptom (syncope) to the diagnosis (SSS). If that cause and effect relationship is not established, the claim is at risk for denial.  

Please use caution when documenting syncope with permanent pacemaker insertions.  If you have any question about this (or any other documentation/coding issue), please stop by my desk. I am located between rooms 5006 and 5007 in the CVCU.