Wednesday, June 17, 2015

Medical decisions by central authority without appropriate expertise---potentially harmful to patients

A recent post from Dr Wes notes:

Today I learned that CMS has issued a National Coverage Decision (NCD) for pacemakers effective 6 July 2015 that would restrict pacemaker implants to patients with "non-reversible symptomatic bradycardia" and require a so-called "KX" modifier to be added to codes for patients needing pacemakers.

That's right, even patients with asymptomatic complete heart block would not be covered.  Patients with asymptomatic Mobitz Type II heart block wouldn't be covered either.  Even though every piece of medical literature has supported the benefits of pacemakers in these indications, it seems doctors will be left with no choice but to lie in their documentation about patient symptoms to assure Medicare payment, or risk the government refusing to pay for their patients' medically indicated care. 

To my reading the original source linked in the post is fuzzy concerning what will and won't be covered ultimately. However the requirement for the KX modifier forces the physician to attest that the patient has symptomatic bradycardia.  That implies that patients with asymptomatic type 2 AV block would be denied permanent pacing, thus exposing them to significant mortality risk. 

So this is either a case of regulatory obfuscation or a top-down medical decision which will place patients at risk. If the latter, it reflects junior medical student level of expertise or worse. Stupidity can be dangerous. 

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