If you were involved with a kyphoplasty audit, this may sound familiar. A number of hospitals and health systems have recently been served with subpoenas by the United States Department of Justice regarding Medicare billing for implantable cardioverter defibrillators (“ICDs”). The DOJ is investigating whether hospitals billed Medicare for ICDs for patients who did not satisfy coverage National Coverage Determination criteria. For example, NCD criteria provides that Medicare does not cover implantation of ICDs in patients who lack a history of arrhythmia, even if their heart function indicates that they are at an elevated risk of sudden death due to arrhythmia, if the implantation occurred within 40 days of an acute myocardial infraction or within three months of a bypass surgery or angioplasty. The DOJ also is investigating the three largest ICD manufacturers regarding their communication with providers regarding Medicare billing – much like the DOJ’s past investigation of Kyphon as part of their kyphoplasty investigation.
The National Coverage Determination criteria can be found in the NCD Manual Section 20.4.
