CardioExchange Archive

CardioExchange welcomes Dr. Jonathan Steinberg, a Columbia University-affiliated electrophysiologist who also directs the EP program at a large suburban nonteaching hospital. A co-author of a JACC special article that describes the federal audit of his hospital’s ICD implants, Dr. Steinberg answers our questions about the audit process.

What should cardiologists do to avoid a federal audit?

It is necessary to be compulsively compliant with the CMS National Coverage Determination (NCD) for ICD indication. Systems should be established so that cardiologists are fully aware of the inclusion and exclusion criteria, and it may be valuable to require concurrent completion of checklists at implant to ensure compliance.

Nonetheless, circumstances may arise that suggest the benefit of an ICD implant, despite potential violation of the NCD. These instances may be judged acceptable upon subsequent review if based on sound published evidence supporting the indication and — very importantly — if there is thorough documentation in the medical record. Our paper outlines several scenarios that fit into this category. It is unwise to perform procedures that fall outside of accepted guidelines for implantation.

What should cardiologists do if they are audited?

Each case should be thoroughly reviewed from the source medical record, even though this is very time consuming. Clinical circumstances that would justify implantation should be identified in the record. If there are cases that clearly violated the NCD without mitigating factors they will need to be conceded.

What practical steps can you recommend for establishing the peer-review oversight mentioned at the end of the article?

It is helpful to have other colleagues who perform implants comment on the appropriateness of ICD implantation prior to surgery — particularly if there is any ambiguity. This can be done on a routine basis to avoid bias. Local quality assurance systems should be employed to provide retrospective review and to present cases that can be used to educate physicians on potential problems with indications or documentation.