Cardiology Coding Alert

Append modifier 52 in some instances.

You may see cases where your cardiologist uses a Holter monitor, also known as dynamic electrocardiography (ECG), to monitor and record a patient’s heart rhythm. During the procedure, your cardiologist will apply an ECG recorder to the patient for up to 48 hours to detect abnormal heart rates and rhythm. However, if you don’t check the documentation for details such as the exact amount of time your cardiologist monitored the patient, you could report the incorrect code.

Check out these expert tips to keep your Holter monitor claims in tip-top shape.

Tip 1: Rely on 93224 for Global Holter Monitoring

If your cardiologist performs the Holter monitoring in their office, where they place the monitor on the patient, record the results, remove the monitor, and interpret the results, you should report 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).

Your cardiologist will also instruct the patient how to use the Holter monitor during this encounter. Additionally, the provider will remove the monitor after 48 hours.

Code 93224 is the global code for Holter monitoring. Remember, since code 93224 represents both the technical and professional components of the service, you should not append modifiers 26 (Professional component) or TC (Technical component).

Tip 2: Observe Holter Component Codes

On the other hand, if your cardiologist performs Holter monitoring but only performs a specific part of the procedure instead of the global service (93224), you should look to the following individual component codes instead:

• For the connection of the device, report 93225 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection)).
• Choose 93226 (External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report) if the physician reports only the scanning analysis of portion of the test.
• For the physician’s review and interpretation only, report 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).

Coding tip: Since component codes 93225-93227 are included in 93224, you should never report them in addition to 93224.

Don’t miss: Codes 93224-93227 include a coverage period of up to 48 hours for one unit of service, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. No other electrocardiogram (EKG) monitoring codes can be billed simultaneously with these codes.

Tip 3: Don’t Forget to Append Modifier 52 for This Scenario

In some cases, your cardiologist may use a Holter monitor for less than 12 hours. The CPT^® coding guidelines for codes 93224-93227 specify that when there are less than 12 hours of continuous recording, you should use modifier 52 (Reduced services), Falbo explains.

For example, your cardiologist attaches a Holter monitor to the patient for seven hours of continuous recording to detect abnormal heart rates and rhythms. Your cardiologist performs all of the components of the monitoring service including the connection, the scanning analysis and report, and the review and interpretation. You should report 93224-52 on your claim because your cardiologist only performed seven hours of continuous recording.

Tip 4: Monitoring Lasts More Than 48 Hours? Do This

Sometimes your cardiologist may perform Holter monitoring that lasts more than 48 hours. In this case, you should look to different codes.

For example, report the following codes for recording that lasts more than 48 hours and up to seven days:

• 93241 (External electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation). Note: Code 93241 is the global code you should report if your cardiologist reports all of the parts of the service including the recording, scanning analysis with report, and the review and interpretation.
• 93242 (… recording (includes connection and initial recording).
• 93243 (… scanning analysis with report).
• 93244 (… review and interpretation).

On the other hand, you should report the following codes to report more than seven and up to 15 days:

• 93245 (External electrocardiographic recording for more than 7 days up to 15 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation). Note: You should report code 93245 for the global service if your cardiologist performs all of the parts of this service.
• 93246 (… recording (includes connection and initial recording)).
• 93247 (… scanning analysis with report).
• 93248 (… review and interpretation).

Tip 5: Beware of Paying Outside Service for Monitoring

Among the pitfalls of billing for Holter monitoring, it is becoming quite common for cardiology practices to “purchase” the actual scan service from an outside source instead of purchasing the expensive software to scan the Holter internally, says Ray Cathey, PA, FAAPA, MHS, MHA, CCS-P, CMSCS, CHCI, CHCC, president of Medical Management Dimensions in Stockton.

“Paying for the scan service done by an outside source could, potentially, fall under the Anti-Markup Payment Limitation: Purchased Diagnostic Tests regulations from the Centers for Medicare & Medicaid Services (CMS),” Cathey explains. “These Stark regulations limit the amount that a provider may pay an outside vendor for the technical component — in this case, the scanning portion of the Holter ‘global’ code (93224) is 93226. This regulation would apply to other ‘purchased services,’ as well.”

When billing globally, code 93224 includes all three of the component codes: 93225-93227. The provider who purchases the scan service from an outside source must be certain to not violate these regulations by paying the scanning service more than that company would have been paid if they had billed code 93226 themselves, Cathey adds. The Medicare Physician Fee Schedule (MPFS) national average price for 93226 is $38.76, so the fee that the “purchasing provider” pays to the scanning provider may not exceed that amount. The actual amount will vary, depending on your Medicare Administrative Contractor’s (MAC’s) jurisdiction/location.

“To complicate matters, the Stark regulations actually extend to all payers, not just Medicare,” Cathey says. “So, it would be necessary to find out what each payer you bill 93224 to allows for the 93226 portion of the global 93224 code. You may not pay the scan service more than they would have gotten if they would have billed the scan code themselves.”

Bottom line: Have your scanning service bill for the 93226 themselves, Cathey explains. This accomplishes two things: It keeps you out of jeopardy of violating the anti-markup limitation/Stark regulations, and it eliminates paying the vendor for services that you may have to appeal before you get paid, if you get paid at all.