Pacemaker and Defilbrillator Implantations Make Prime RAC Targets

Cardiac Pacemaker Implantations and Cardiac Defibrillator Implantations were two of the most targeted services from an overpayment standpoint during the RAC demonstration period.  This makes them potential prime targets for the permanent RACs in the future.  As such, sufficient documentation of the need for services provided at the inpatient level of care are paramount when providing these services, due to increased scrutiny they will undoubtedly receive from the permanent RACs once approved.  CMS recently noted the high probability of overpayment in connection with these claims in an MLN Matters article.

To date, neither pacemaker implants nor defibrillator implants have been approved for medical necessity reviews by the RACs.  But the potential for recoupment suggests these procedures will be approved for medical necessity review in the future.  Currently, the permanent RACs are reviewing percutaneous cardiovascular procedures and other vascular procedures for medical necessity in all four regions.

Providers need to be prepared to show the medical necessity of the inpatient stay for cardiac implantations in the medical record.  If you would like additional information regarding preparing for RAC reviews or would like to have your current procedures reviewed for compliance, please contact a Wachler & Associates attorney at 248-544-0888.