Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or
Real-Time Monitoring)

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
associated LCD Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-
Time Monitoring) L34636

**Guidelines**  
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits.
This information does not take precedence over CCI edits. Please refer to CCI
for correct coding guidelines and specific applicable code combinations prior
to billing Medicare.

1\. CPT codes for Holter monitoring services (CPT codes 93224-93227) are
intended for up to 48 hours of continuous recording.

  * The documentation in the progress notes must reflect medical necessity for the service.
  * These services may be reported globally with CPT codes 93224. Use the date of physician review as the date of service (DOS).
  * When submitting claims for the recording only (CPT code 93225) or for the analysis with report only (CPT code 93226) use the date the service was performed as the DOS.
  * When submitting claims for physician review and interpretation (CPT code 93227) use the date the service was performed as the DOS.
  * For less than 12 hours continuous recording, modifier -52 (reduced services) should be appended.

2\. List the diagnosis code(s) indicating the reason for the test.

3\. The physician interpreting the test must be identified on the claim form
with his/her sequence number in Box 24K.

4\. The codes describing technical work may be billed by an independent
diagnostic testing facility (IDTF) if they meet all requirements listed in the
code descriptions and coverage requirements. They may bill the total component
only if the physician interpreting the test is employed or contracted by the
IDTF and is not billing for the interpretation separately. The physician's
name and address must be on record with our WPS Provider Enrollment
Department. A letter should be sent by the physician assigning all monies
collected by the IDTF for the professional codes to the billing IDTF. If a
letter is not on file, professional services billed by the IDTF will be
denied.

5\. Do not use the "TC" or "26" modifier with the codes 93224-93229, 93268,
93270, 93271, or 93272, listed in the CPT/HCPCS section of the LCD.

6\. For the same dates of service, either the wearable patient monitor or the
up to 48-hour monitor will be covered (not both).

**External Mobile Cardiac Telemetry Monitors**  
CPT codes 93228 and 93229 describe wearable mobile cardiovascular telemetry
services. Providers are instructed to bill one (1) unit of procedure code
93228 and/or 93229 per a course of treatment that includes up to 30
consecutive days of cardiac monitoring.

CPT code 93229 is the technical component of this service and includes all of
the following within a course of treatment that includes up to 30 consecutive
days of cardiac monitoring:

  1. Patient hook-up and patient-specific instruction and education
  2. Transmission and receipt of ECG
  3. Analysis of ECG by nonphysician personnel
  4. Medical chart documentation including daily report, patient and/or physician interaction and response, and summary report at the end of the monitoring episode
  5. Equipment maintenance
  6. All supplies necessary for completion of the monitoring.

CPT code 93228 is the professional component of this service and includes
review and interpretation of each 24-hour cardiac surveillance as well as
24-hour availability and response to monitoring events within a course of
treatment that includes up to 30 consecutive days of cardiac monitoring.  
  
The following documentation requirements apply to all claims reporting CPT
code 93228 and/or 93229:

  1. The date of service must be reported as the date the patient was initially placed on the monitor.
  2. A monitoring episode (one to 30 consecutive days) is reported as a unit of one.
  3. Any additional claims reporting procedure code 93228 or 93229 for ECG arrhythmia detection and alarm system within an episode of care (one to 30 days after an initial service) will be denied.

**Types of monitoring and coverage:**

  1. CPT Codes 93224-93227  
Continuous up to 48-hour Monitoring (CPT codes 93224-93227), includes a
coverage period of up to 48-hours for one unit of service. No other EKG
monitoring codes can be billed simultaneously with these codes.

  2. CPT Codes 93241-93248  
Long-term continuous recorders continuously record and store for greater than
48 hours and up to 7 days or for greater than 7 days up to 15 days. No other
EKG monitoring codes can be billed simultaneously with these codes and
services represented by these codes are non- covered for inpatient or
outpatient observation care. (Refer to current CPT codebook)

  3. CPT codes 93268-93272  
 _Cardiac event monitor technology varies among different devices. For
patient-activated event monitors, the patient initiates recording when
symptoms appear or when instructed to do so by a physician (e.g., following
exercise). For self-sensing automatically triggered monitors, an EKG is
automatically recorded when the device detects an arrhythmia, without patient
intervention. Some devices permit a patient to transmit EKG data
transtelephonically (i.e., via telephone) to a receiving center where the data
is reviewed. A technician may be available at these centers to review
transmitted data 24 hours per day. In some instances, when the EKG is
determined to be outside certain pre-set criteria by a technician or other
non-physician, a physician is available 24 hours per day to review the
transmitted data and make clinical decisions regarding the patient. These
services are known as "24-hour attended monitoring". In other instances,
transmitted EKG data is reviewed at a later time and are, therefore,
considered "non-attended." (CMS Pub 100-03, Medicare National Coverage
Determinations (NCD) Manual, _Chapter 1, Part 1, 20.15 Electrocardiographic
Services).

  
The person receiving the transmission must be a technician, nurse, or a
physician trained in interpreting ECG's and abnormal rhythms.  
A physician must be available 24 hours a day for immediate consultation to
review the transmission in case of significant symptoms or ECG abnormalities

**_Nationally Non-Covered Indications_**

_The following indications are non-covered nationally unless otherwise
specified below:_

  1. _The time-sampling mode of operation of ambulatory EKG cardiac event monitoring/recording._
  2. _Separate physician services other than those rendered by an IDTF unless rendered by the patient's_  
 _attending or consulting physician._

  3. _Home EKG services without documentation of medical necessity._
  4. _Emergency EKG services by a portable x-ray supplier without a physician in attendance at the time of_  
 _the service or immediately thereafter._

  5. _24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI unless provision is made for such 24-hour attended coverage in the manner described in section 4 above._

_(CMS Pub 100-03, Medicare National Coverage Determinations (NCD) Manual,
Chapter 1, Part 1- Coverage Determinations, 20.15 Electrocardiographic
Services)_