Article - Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)

CMS National Coverage PolicyItalicizedfont represents CMS national language/wording copied directly from CMS Manuals or CMS transmittals. Contractors are prohibited from changing national language.Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a) (1) (D). This section states that no Medicare payment may be made under part A or part B for any expenses incurred for items or services that are investigational or experimental.Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.42 CFR, Section 410.32Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses ther results in the management of the beneficiarys specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.42 CFR, Section 411.15(k)(1) states any services that are not reasonable and necessary are excluded from coverage.Article TextThe 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) L34636GuidelinesThe 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 MonitorsCPT 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:Patient hook-up and patient-specific instruction and educationTransmission and receipt of ECGAnalysis of ECG by nonphysician personnelMedical chart documentation including daily report, patient and/or physician interaction and response, and summary report at the end of the monitoring episodeEquipment maintenanceAll 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:The date of service must be reported as the date the patient was initially placed on the monitor.A monitoring episode (one to 30 consecutive days) is reported as a unit of one.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:CPT Codes 93224-93227Continuous 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.CPT Codes 93241-93248Long-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)CPT codes 93268-93272Cardiac 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 abnormalitiesNationally Non-Covered IndicationsThe following indications are non-covered nationally unless otherwise specified below:The time-sampling mode of operation of ambulatory EKG cardiac event monitoring/recording.Separate physician services other than those rendered by an IDTF unless rendered by the patient'sattending or consulting physician.Home EKG services without documentation of medical necessity.Emergency EKG services by a portable x-ray supplier without a physician in attendance at the time ofthe service or immediately thereafter.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)