Cardiology Coding Alert

Holter monitors are standard tools used by cardiologists to diagnose cardiac rhythm irregularities. Yet consultant Ray Cathey, PA-C, president, Medical Management Dimensions, a coding and reimbursement consulting firm in Stockton, CA, tells us he sees coders making two major mistakes when billing Holter monitors (93224-93233).

1. Confusing two sets of codes. Both 93224 and 93230 have the same goal: to evaluate the patients ambient heart rhythm by obtaining a continuous ECG waveform recording. (A waveform is a graph of an electrical deviation.) Both procedures also begin the same way: ECG leads are placed on the patients chest, the patient wears the recorder for 24 hours, he or she returns, and the recorder is disconnected. But the two codes are not interchangeable, says Cathey.

The difference lies in the type of technology each procedure uses, he explains. For example, in 93224, specially trained technicians scan the patients waveform generated by the monitor and compare it with a normal waveform to identify variances. This is called superimposition, Cathey explains. The graphic recording compares the patients heartbeat with normal beats to see how they match up. A permanent record of every beat is often not available.

But 93230 does not use superimposition. Instead, in this procedure, a microprocessor analyzes the data and produces a printout of all recorded data in a miniaturized display. With this procedure, the physician can get a 24-hour printout and look at the beats himself, he says.

Although the procedure described in 93230 is the more sophisticated of the two technologiesand it pays slightly moremany cardiologists still use 93224. So if the charge sheet says Holter monitor, check to see which procedure was actually performed, he advises.

Note: Code 93235 is listed immediately below Holter monitors in the CPT, and has a similar description. But it indicates another tool to evaluate rhythm problems (an event recorder), and should not be used when a Holter monitor is the actual diagnostic device. An event monitor differs from a Holter monitor in that with an event monitor the patient pushes a button on a device.

2. Unbundling the Holter monitor. The second biggest mistake Cathey sees coders make is charging all three of the component codescomplete, technical, and professionalwhen the cardiologist performed the global procedure.

Note: Do not append modifier -26 on the global code because this series contains separate codes that specify the professional component.

Billing all three codes (93225-93227, 93231-93233) beneath the primary code (93224 or 93230) is not appropri-
ate; yet, I see a huge number of practices that do this, he says. If there is a code that represents the global procedure, you have to use it. In this case, the complete code is either 93224 or 93230. (See Correct Coding Initiative on this page.)

However, you can use component codes if your cardiolo-
gist only performs part of the procedure. For example, if an ECG technician at the hospital hooks up the Holter monitor, the hospital would bill either 93225 or 93231 for the recording, depending on what type of device was used.

Note: If your cardiologist performs this service, you can bill for it. But you can only bill for 93225 or 93231 once. You cant bill for it again when it is disconnected because that work is included in the initial code.

If an outside company performs the scanning, it would bill for 93226 or 93232. But if your office has the scanning equipment and performs that function, you should bill for it.

Finally, all cardiology practices should be billing for at least 93227 or 93233, because the report (although run by either a technician or a computer) must be reviewed and interpreted by a physician.