Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 05.00.29k


Attachment:B

Policy #:05.00.29k

Description:ICD-10 codes used to represent the Nonwearable Automatic External Defibrillator (AED):

Title:Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



A NONWEARABLE DEVICE (E0617) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery

I21.29 ST elevation (STEMI) myocardial infarction involving other sites

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site

I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I21.9 Acute myocardial infarction, unspecified

I21.A1 Myocardial infarction type 2

I21.A9 Other myocardial infarction type

I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites

I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

I25.2 Old myocardial infarction

I42.1 Obstructive hypertrophic cardiomyopathy

I42.2 Other hypertrophic cardiomyopathy

I45.81 Long QT syndrome

I46.2 Cardiac arrest due to underlying cardiac condition

I46.8 Cardiac arrest due to other underlying condition

I46.9 Cardiac arrest, cause unspecified

I47.0 Re-entry ventricular arrhythmia

I47.2 Ventricular tachycardia

I49.01 Ventricular fibrillation

I49.02 Ventricular flutter

T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter

T82.110D Breakdown (mechanical) of cardiac electrode, subsequent encounter

T82.110S Breakdown (mechanical) of cardiac electrode, sequela

T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter

T82.111D Breakdown (mechanical) of cardiac pulse generator (battery), subsequent encounter

T82.111S Breakdown (mechanical) of cardiac pulse generator (battery), sequela

T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter

T82.118D Breakdown (mechanical) of other cardiac electronic device, subsequent encounter

T82.118S Breakdown (mechanical) of other cardiac electronic device, sequela

T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter

T82.119D Breakdown (mechanical) of unspecified cardiac electronic device, subsequent encounter

T82.119S Breakdown (mechanical) of unspecified cardiac electronic device, sequela

T82.120A Displacement of cardiac electrode, initial encounter

T82.120D Displacement of cardiac electrode, subsequent encounter

T82.120S Displacement of cardiac electrode, sequela

T82.121A Displacement of cardiac pulse generator (battery), initial encounter

T82.121D Displacement of cardiac pulse generator (battery), subsequent encounter

T82.121S Displacement of cardiac pulse generator (battery), sequela

T82.128A Displacement of other cardiac electronic device, initial encounter

T82.128D Displacement of other cardiac electronic device, subsequent encounter

T82.128S Displacement of other cardiac electronic device, sequela

T82.129A Displacement of unspecified cardiac electronic device, initial encounter

T82.129D Displacement of unspecified cardiac electronic device, subsequent encounter

T82.129S Displacement of unspecified cardiac electronic device, sequela

T82.190A Other mechanical complication of cardiac electrode, initial encounter

T82.190D Other mechanical complication of cardiac electrode, subsequent encounter

T82.190S Other mechanical complication of cardiac electrode, sequela

T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter

T82.191D Other mechanical complication of cardiac pulse generator (battery), subsequent encounter

T82.191S Other mechanical complication of cardiac pulse generator (battery), sequela

T82.198A Other mechanical complication of other cardiac electronic device, initial encounter

T82.198D Other mechanical complication of other cardiac electronic device, subsequent encounter

T82.198S Other mechanical complication of other cardiac electronic device, sequela

T82.199A Other mechanical complication of unspecified cardiac device, initial encounter

T82.199D Other mechanical complication of unspecified cardiac device, subsequent encounter

T82.199S Other mechanical complication of unspecified cardiac device, sequela

T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter

T82.6XXD Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter

T82.6XXS Infection and inflammatory reaction due to cardiac valve prosthesis, sequela

T82.7xxA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter

T82.7xxD Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter

T82.7xxS Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela

Version Effective Date: 12/27/2017
Version Issued Date: 12/27/2017
Version Reissued Date: 07/17/2019

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.