Cardiology Coding Alert

Don’t miss: Understand when to appropriately append modifier 52.

Holter monitoring is one way your cardiologist may monitor and record a patient’s heart rhythm. However, if you don’t know exactly how long the cardiologist performed continuous recording with the Holter monitor, you could get into serious hot water.

Answer the following questions to keep your Holter monitoring claims in tip-top shape.

Editor’s note: Tune in to next month’s issue of Cardiology Coding Alert to learn even more about another type of cardiac monitoring — cardiac event recorders.

First, Define Holter Monitoring for Clarity

Question 1: What is Holter monitoring?

Answer 1: With dynamic electrocardiography (ECG), also referred to as Holter monitoring, the cardiologist applies an ECG recorder to a patient for up to 48 hours to detect abnormal heart rates and rhythm. A Holter monitor continuously records the patient’s heart rhythm.

Turn to 93224 for Global Service

Question 2: The patient has an irregular heart rhythm that comes and goes, so based upon his symptoms, my cardiologist ordered a Holter monitor. In his office, the cardiologist attached the monitor to the patient, and the cardiologist performed continuous recording for 24 hours. The cardiologist analyzed, compiled, and interpreted the electrocardiographic findings. When the test results came back, they showed that the patient definitely has paroxysmal atrial fibrillation. What code should I report for this service?

Answer 2: If the exam is performed in the physician’s office, where the monitor is placed on the patient, recorded, removed, and interpreted by the physician or other qualified health care professional, then report the global code 93224 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional), explains Jim Pawloski, BS, MSA, CIRCC, R.T. (R)(CV), interventional radiology technologist/coder at William Beaumont Hospital in Royal Oak, Michigan, and coder at Adreima in Phoenix, Arizona.

In your case, the cardiologist since the cardiologist did perform all of the components of Holter monitoring including the connection, the scanning analysis and report, and the review and interpretation, you should report 93224. You should also connect the diagnosis code I48.0 (Paroxysmal atrial fibrillation) to 93224 on your claim to show medical necessity for the testing.

Report Separate Components of Holter Monitoring With These Codes

Question 3: My cardiologist performed Holter monitoring, but he did not perform the global service. Which code should I report?

Answer 3: You can report the individual components (93225-93227) of the Holter monitoring service if your cardiologist only performs a specific part of the procedure. In your case, you should carefully check the documentation carefully to see exactly what service your cardiologist performed. Then, when you have that information, you can look at the following codes:

• 93225 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)). For the connection of the device, you would report 93225.
• 93226 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report). You would choose 93226 if the physician reports only the scanning analysis of portion of the test.
• 93227 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional). For the physician’s review and interpretation, opt for 93227.

Don’t miss: Component codes 93225-93227 are included in 93224, so you should not report them individually with 93224, per CPT^® Assistant Vol. 21, No. 10.

Append Modifier 52 Under These Circumstances

Question 4: Under what circumstances would we need to append modifier 52 (Reduced services) to the Holter monitor codes?

Answer 4: When you report Holter monitor codes 93224-93227, and the cardiologist performs less than 12 hours of continuous recording, you should append modifier 52 to the appropriate Holter monitor code, according to CPT^® Assistant Vol. 21, No. 10.

Coding scenario: To detect abnormal heart rates and rhythms, the cardiologist attaches a Holter monitor to the patient for 10 hours of continuous recording. The cardiologist performs all of the components of the service including the connection, the scanning analysis and report, and the review and interpretation.

Coding solution: For this procedure, you would report 93224, and you would append modifier 52 to this code since the cardiologist only performed 10 hours of continuous recording.

Rely on T-Codes Under These Circumstances

Question 5: My cardiologist performed Holter monitoring, but it lasted more than 48 hours. How should I report this?

Answer 5: You should only report Holter monitor codes 93224-93227 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional) when the cardiologist performs up to 48 hours of continuous recording, per the code descriptors.

In your case, since the cardiologist performed more than 48 hours of monitoring, you should instead look to codes 0295T (External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation)-0298T (External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation), according to a parenthetical note in the CPT^® guidelines.

Outside Service Performed Holter Scanning? Not so Fast

Question 6: Can I report the global code 93224 for Holter monitoring when an outside service performs the scanning?

Answer 6: No, experts say.

“The most common error I see with Holter monitor coding is billing globally (93224) when an outside service is doing the scanning,” says Ray Cathey, PA, FAAPA, MHS, MHA, CCS-P, CMSCS, CHCI, CHCC, president of Medical Management Dimensions in Stockton. “It is a Stark Law violation to pay a vendor more than they would get if they had billed directly. The provider should check what the payer would have paid the vendor that they have contracted with for a 93226 (scan analysis with report), and they may not pay the vendor any more than that amount. Paying more than that amount is not permitted with all payers, not just Medicare.”

Cathey continues by advising how providers can avoid making this error.

“To avoid this problem, providers should not contract with vendors to pay them a set fee for the scan,” Cathey adds. “They should bill the 93227 for the physician review and interpretation and the 93225, but only if they hook the patient up to the device.”