Cardiology Coding Alert

12, 24, and 48 hour services all have roles in this coding shake-up.

Cardiology codes are always changing, trying to keep pace with technology and current practice. For this reason, Holter monitor codes saw big changes this year. Here's what you need to know.

Start With a Nutshell Holter Service Description

Dynamic electrocardiography (ECG), also called Holter monitoring, involves ECG recording, usually over 24 hours. The goal is to obtain and analyze a record of the patient's ECG activity during a typical day.

The medical record usually will include the reason for the test, copies of ECG strips showing abnormalities or symptomatic episodes, the patient's diary of symptoms, statistics for abnormal episodes, the physician's interpretation, and documentation of recording times.

Understand Your Newly Reduced Coding Options

In 2010, you chose among the following code ranges for these services:

• 93224-93227, Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning ...
• 93230-93233, Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout ...
• 93235-93237, Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous computerized monitoring and noncontinuous recording, and real-time data analysis using a device capable of producing intermittent full-sized waveform tracings, possibly patient activated ...

In 2011, your coding options have changed. A new note under 93229 tells you "93230-93237 have been deleted. To report external electrocardiographic rhythm derived monitoring for up to 48 hours, see 93224-93227." CPT® Changes 2011: An Insider's View states that 93224-93227 have been revised to accommodate reporting the services described by 93230-93233 and 93235-93237.

Result: The definitions of 93224-93227 now begin with: "External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage ..." You can see that one of the major changes to 93224-93227 is that they now officially refer to "up to 48 hours" instead of "24 hours."

Tip: Older Holter models cannot hold the complete 48 hours at one time. If the memory is full, new data will overwrite the old, so the stored memory must be retrieved shortly after the initial 24-hours. Modifier 76 (Repeat procedure or service...) may be appropriate if the payer requires the initial data to have its own date of service (DOS). Newer models may allow recording the full 48 hours, but your practice needs to be sure to follow manufacturer instructions.

For example, the device may have a flashcard that has a default setting of 24 hours that the staff will need to reset to 48 hours to match patient needs. This is a prime example of when it is important to know what product styles and models your practice carries and how the product operates.

If the service is on the opposite extreme, with less than 12 hours ofcontinuous recording, take care. A parenthetical note with 93224-93227 says you must append modifier 52 (Reduced services) to the Holter code in that case, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of Terry Fletcher Consulting in Laguna Beach, Calif. 93224-93227

Stay in the Comfort Zone

Now that you have the broad overview, dive into the specific services described by these codes, comparing how to report 2010 and 2011 services.

Old way: In 2010, you used 93224-93227 for services related to specially trained technicians visually scanning patient waveforms generated by the monitor. The technicians compared these waveforms to a normal waveform to identify discrepancies. Codes 93224-93227 differed based on whether they represented the global service or different components of the service:

• Global: 93224, ... includes recording, scanning analysis with report, physician review and interpretation
• Recording: 93225, ... recording (includes hook-up, recording, and disconnection)
• Scanning: 93226, ... scanning analysis with report
• Interpretation: 93227, ... physician review and interpretation.

In other words: Codes 93225-93227 represented different components of the work associated with the Holter monitor service. When your physician group provided all three of these services, you reported 93224.

New way: In 2011, you should continue to use 93224-93227 for the services described above. Practically speaking, cardiology practices often outsource the work represented by 93226 because they do not have the needed technology. In that case, report 93225 and 93227. Typically you'll use the hook-up date as the DOS for 93225 and the physician's interpretation date as the DOS for 93227. Payers have been to known to deny 93225 and 93227 when reported with the same DOS.

Smart move: If you're seeing denials for these codes, check your payer contract. Sometimes itemized codes like 93225-93227 can cause problems because a payer contract only refers to the full service code, such as 93224, says Fletcher.

93230-93233 Services See Shift

Old way: You used 93230-93233 when a microprocessor analyzed the data and produced a printout of all recorded data in a miniaturized display.

As with 93224-93227, 93230 described the global service, while the other codes in the family represented specific pieces of that global service.

New way: In 2011, you should use 93224-93227 for the services described above. 93235-93237 Are Discontinued

Old way: You used 93235-93237 when the patient wore a long-term ECG monitor for 24 hours, but the recording was noncontinuous. For instance, the cardiologist could schedule a recording for certain time periods, abnormal heart rhythms could trigger a recording, or the patient could choose to record.

You reported this type of monitoring with global code 93235 only if the physician performed all of the services. Otherwise, you reported the code specific to the component performed.

New way: In 2011, remember the instruction that to "report external electrocardiographic rhythm derived monitoring for up to 48 hours, see 93224-93227." Beware of inappropriately using mobile cardiac telemetry codes 93228-93229 or event monitor codes 93268-93272, which require attended surveillance (meaning a remote technician is immediately available to respond to alerts).