Cardiology Coding Alert

Beware of PC/TC issues for transtelephonic PM monitoring, too.

After a pacemaker is in place, a patient requires ongoing monitoring to ensure the pacemaker is doing its job.

Problem area: “In our consulting experience, we see issues meeting the frequency guidelines for transtelephonic monitoring,” says Mary I. Falbo, MBA, CPC, president and CEO of Millennium Healthcare Consulting Inc. Review these four questions to help boost your understanding of the guidelines.

1. Where Can You Go to Review Guidelines?

To get on your way to complying with transtelephonic monitoring frequency guidelines, read Medicare’s National Coverage Determination (NCD), says Falbo. Also check for a Local Coverage Determination (LCD) from your MAC.

You’ll find the NCD in Section 20.8.1.1, Transtelephonic Monitoring of Cardiac Pacemakers, in the Medicare National Coverage Determination Manual (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf).

You also can find Medicare policies in the Medicare Coverage Database at www.cms.gov/medicare-coverage-database/. You may use the database to search for both NCDs and LCDs.

2. Why Does CMS Cover Transtelephonic PM Monitoring?

The NCD explains that Medicare covers telephone monitoring of pacemakers because the service helps lower the risk of sudden failure by identifying failure’s early signs. Monitoring systems can detect subclinical failure caused by a drained battery. Some monitoring systems can detect additional problems such as internal electronic issues.

For dual-chamber pacemakers, monitoring can detect problems with synchronizing the atria and ventricles, alerting the cardiologist to the need to adjust and reprogram the pacemaker.

3. What Is Transtelephonic Monitoring?

CPT^®: In the guidelines for cardiac device evaluation services, CPT^® offers a definition of transtelephonic rhythm strip pacemaker evaluation, commonly known as transtelephonic pacemaker monitoring. The service involves the transmission of an ECG rhythm strip over the telephone.

The patient performs the transmission using a transmitter. Tip: The NCD indicates, “Those engaged in transtelephonic pacemaker monitoring should reflect the costs of the transmitters [furnished to the patient] in setting their charges for monitoring.”

A receiving location uses a receiver to record the transmission. The ECG rhythm strip recording occurs both with and without a magnet applied over the pacemaker.

The provider evaluates the rhythm strip to check the heart rate and rhythm. The provider also evaluates any observed atrial and ventricular capture and sensing. Measurement of the paced rate on the ECG rhythm strip when the magnet is applied determines the battery status.

CMS: As the previous section explained, CPT^® lists strip recording both with and without a magnet applied as part of the monitoring service. In the NCD, CMS provides minimum times for the strips. The NCD states that to cover transtelephonic monitoring, the services must include these elements:

• A minimum 30-second readable strip of the pacemaker in the free-running mode
• Unless contraindicated, a minimum 30-second readable strip of the pacemaker in the magnetic mode
• A minimum 30 seconds of readable ECG strip.

4. Do Performance Frequency and Reporting Frequency Match?

Reporting frequency: The code for transtelephonic pacemaker monitoring is 93293 (Transtelephonic rhythm strip pacemaker evaluation[s] single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report[s] by a physician or other qualified health care professional, up to 90 days).

Under this code is an instruction to “Report 93293 only once per 90 days,” which supports the element at the end of the 93293 code descriptor that states “up to 90 days.”

Maximum performance frequency: The NCD instructs MACs to combine the frequency guidelines it provides with knowledge of local medical practices to screen monitoring claims. For instance, the patient’s condition or issues with the pacemaker may justify more frequent monitoring.

The practice should ensure that it meets the frequency parameters by tracking these services in the EMR, Falbo advises.

CMS divides the guidelines into two broad categories, Falbo explains, quoting the NCD:

• Guideline I, which will apply to the majority of pacemakers now in use
• Guideline II, which will apply only to pacemaker systems (pacemaker and leads) for which sufficient long-term clinical information exists to assure that they meet the standards of the Inter-Society Commission for Heart Disease Resources (ICHD) for longevity and end-of-life decay.
• Guidelines I and II break down again based on whether the pacemaker is a single-chamber or dual-chamber device, as shown in the bullet list below.

According to the NCD, you should “alert MACs to any changes in the patient’s monitoring prescription that might necessitate changes in the screening guidelines applied to that patient. (Of particular importance is the reprogramming of a dual-chamber pacemaker to a single-chamber mode of operation. Such reprogramming would shift the patient from the appropriate dual-chamber guideline to the appropriate single-chamber guideline.)”

• Guideline I

              1 - Single-chamber pacemakers
                    1st month - every 2 weeks
                    2nd through 36th month - every 8 weeks
                    37th month to failure - every 4 weeks

              2 - Dual-chamber pacemaker
                    1st month - every 2 weeks
                    2nd through 6th month - every 4 weeks
                    7th through 36th month - every 8 weeks
                    37th month to failure - every 4 weeks

• Guideline II

              1 - Single-chamber pacemakers
                    1st month - every 2 weeks
                    2nd through 48th month - every 12 weeks
                    49th through 72nd month - every 8 weeks
                    Thereafter - every 4 weeks

              2 - Dual-chamber pacemaker
                    1st month - every 2 weeks
                    2nd through 30th month - every 12 weeks
                    31st through 48th month - every 8 weeks
                    Thereafter - every 4 weeks

Bottom line: CMS guidelines indicate a general rule for how often monitoring is medically necessary, but that does not mean you should report each monitoring service separately. Report 93293 once every 90 days that you provide a monitoring service, whether you provide one service or more.

Example: A scenario in CPT^® Assistant (February 2009) demonstrates how the reporting frequency and performance schedule of 93293 do not match one-for-one: “If a patient with a pacemaker is nearing elective battery replacement and warrants frequent device checks, such as weekly, it may be clinically appropriate to perform multiple evaluations within a 90-day period; however, only one code can be reported every 90 days.”

Final correct coding tip: The Medicare Physician Fee Schedule divides 93293 into separate professional and technical components, so if your practice provides only the provider’s review and report, be sure to append modifier 26 (Professional component). The monitoring facility will report the technical component.