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Checklist: Cardiac defibrillator implant w/o cardiac cath

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for cardiac defibrillator implant w/o cardiac cath (DRG 226 and 227) services.

It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation. 

Check Documentation description
  Name of beneficiary and date of service in all documentation.
 

A complete inpatient certification that contains the following:

  • Signed and dated by a physician prior to discharge
  • Reason for inpatient admission
  • Estimated and/or actual hospital time
  • Progress notes support the reason for admission and explain current treatment. plans
  • Post-hospital care plans
  • Valid inpatient admission order
 

A complete admission order that contains the following:

  • Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar:
    • Written order
    • Verbal order (which includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar, Identification of the ordering physician/practitioner and countersigned and dated by a physician/practitioner)
    • Written at or before the time of the inpatient admission
    • Authenticated prior to discharge
 

Exceptions or unforeseen circumstances:

  • Patient’s death
  • Patient transferred to another facility
  • Patient left against medical advice (AMA)
  • Unexpected recovery is clearly documented in medical record
  • Other
  Signed, timed, and dated physician orders for each day of care / service.
  History and physical.
  Legible physician progress notes.
  All diagnostic and laboratory reports, as applicable.
  Surgical procedure reports.
  Anesthesia reports.
  Medication administration record.
  Nurses' notes.
  Ambulance run sheet.
  Discharge summary.
  Signature log or physician’s attestation for any missing signatures.
  Signed advanced beneficiary notice of noncoverage (ABN).
  Signed health insurance notice of non-coverage (HINN).
  Any other clinical records that support the medical necessity of the service billed.
  Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the letter.
  Records of patient's condition before, during and after submitted billing period to support medical necessity and reason services were provided
  History and physical, progress notes, office visit notes, cardiology consultations and all other pertinent medical records
  Documentation to support patient does not have irreversible brain damage from preexisting cerebral disease
  Documentation of the history and duration of unsuccessful medical management
  Diagnostic test results/reports to support any applicable cardiac findings such as ventricular arrhythmia, the LVEF, a prior MI or prior cardiac intervention
  Complete legible operative report outlining operative approach used and all the procedure components performed that includes sufficient detail to allow reconstruction of ICD insertion
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy.

 

Disclaimer 
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.