r*MC503*r
PROVIDENCE HOSPITAL
6801 Airport Boulevard, Mobile AL 36608,
251/633−1000
Implantable Cardioverter Defibrillator (ICD) Implementation Checklist (CMS NCD 20.4)
The following Critical Steps are based on the Providence Hospital policy "Scheduling of ICD Impant Procedures
Subject to National Coverage Determination 20.4."
Scheduling associates have a current listing of local Responsible Physicians who have privileges to schedule
and perform ICD procedures
Completed by:
Name and Date
Policy Critical Step
Section
1.0
1. Prior to confirming the ICD implant procedure the scheduling associate has
forwarded the Screening Tool to the Responsible Physician for completion.
1.1.2
2. The Responsible Physician or his/her designee has completed the ICD Screening
Tool.
1.1.4
3. The completed ICD Screening Tool has been reviewed by Staff Reviewer to
determine whether the patient meets NCD 20.4 criteria
2.0
4. NCD criteria met: Procedure was confirmed in the scheduling system and
inpatient/outpatient status was accurately entered in the computer system
(compare with written order),
2.0
5. NCD criteria met: The Responsible Physician was notified that the ICD Implant
procedure has satisfied the relevant criteria, and was informed of the procedure’s
date and time in accordance with hospital policy.
3.0
6. NCD criteria not met:
a) The Responsible Physician was notified that the ICD implant procedure will
not be scheduled due to failure to meet the relevant NCD 20.4 criteria.
b) Additional documentation has been requested from the Responsible Physician
to support the medical neccessity for the ICD procedure.
7. NCD criteria not met: The Responsible Physician did not respond to the
request for supplemental documentation, or the Staff Reviewer determined that , in
spite of the supporting documentation, the proposed ICD implant procedure still
failed to meet NCD 20.4 criteria and the case was referred to a Qualified Physician
Reviewer for further review.
3.3.i
3.2
8. NCD criteria met: The Qualified Physician Reviewer determined that the
proposed ICD implant procedure did meet NCD 20.4 criteria. Complete steps 4, 5,
and 6.
3.0
9. NCD criteria not met: The Qualified Physician Reviewer determined that the
proposed ICD implant procedure did not meet NCD 20.4 criteria. Proceed to step
6.a above.
10. NCD criteria not met: The Responsible Physician deemed the procedure
medically necessary in the interest of patient care and/or patient safety, and prior to
proceeding, has contacted the hospital’s Corporate Responsibility Officer, General
Counsel, or their designee for further action.
4.0
Note: Do not bill Medicare for those ICD implant procedures that fail to
meet the applicable NCD criteria.
5.0
11. Following implant, ICD Registry information was completed and
submitted to the NCDR ICD Registry by Cardiovascular Services.
Date Printed:
CATH0031