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