Cardiology Coding Alert

What is the ILR and how does it work? The insertable loop recorder, which is inserted just under the skin of the chest, is about 2 inches long, three-fourths of an inch wide, and a third of an inch thick, says Bob Thompson, MA, MS, clinical systems program manager for Medtronic, Inc., the medical technology company headquartered in Minneapolis that manufactures the device. The electrodes that sense the hearts activity are on the surface of the device (just under the skin), so no transvenous leads are necessary, Thompson explains. Because the device is slipped completely under the skin, patients can bathe, swim and engage in other activities that may be difficult or impossible with external monitoring devices such as a Holter monitor or event recorder. When symptoms occur, the patient uses a hand-held activator to store a segment of ECG into the devices memory. After an event is recorded, the patient visits the physicians office to have the ECG retrieved from the ILRs memory. Using a Medtronic programmer, the physician retrieves the ECG data via telemetry, and can review it either on the programmer screen or a print out. The process is similar to that of retrieving data from a pacemaker. It has a presymptom memory loop that will capture infrequent but recurring episodes of syncope up to four and a half months apart, Thompson says. Because it can record the period of time before and after an episode, it can capture a record of a symptomatic heart event even after symptoms pass. The device, which can be programmed to store up to 42 minutes of ECG, has an estimated minimum life of one year after insertion.

Diagnosing the cause of intermittent episodes of syncope has long challenged cardiology practices. But this year the Food and Drug Administration (FDA) approved an implantable heart monitor -- the Reveal Insert Loop Recorder (ILR) -- that continually records a subcutaneous electrocardiogram (ECG).

Yet coding for new cardiology technology carries its own set of challenges. For example, the ILR should probably be coded as 33999, Unlisted procedure, cardiac surgery; however, in some states, Medicare automatically rejects any code for unlisted procedures.

A CPT code specific for the device is expected in the year 2000. Meanwhile, cardiology practices need to go the extra mile in filing a claim for an insert loop recorder -- if they want to get maximum reimbursement and avoid the appeals process -- even if using the unspecified code, says Cynthia Swanson, RN, CPC, management consultant with Seim, Johnson, Sestak & Quist in Omaha, NE.

She explains that Medicare payers will look for supporting documentation as well as specific elements on a claim.

1. Is the device investigational?

2. Is it effective?

3. Is it backed up by sound clinical research?

4. Is the medical necessity for the service supported?

It does take extra work on the front end, but if you only list the unspecified code, you may be setting yourself up for an automatic rejection, says Swanson.

Thats why cardiology practices should get coding
clarification from their local Medicare carrier as well as other payers the first time an insert recorder is billed.

Take the initiative and start the dialog. Find out ahead of time what coding and billing information is required, so you wont automatically have to go into the reconsideration/appeals process, she suggests. You should only have to do it once per payer.

Remember that Medicare does not prior authorize services that are already covered benefits.

So this letter should not be to seek prior authorization, but rather to seek coding and billing clarification for a
new technology, Swanson states.

She explains the letter should begin by seeking coding clarification and then contain the following elements:

1. The purpose of the ILR system. Explain what the device is and that it is used for patients whose symptoms, such as syncope, are infrequent, recurrent and unexplained, she says.

The letter should also explain why typical monitoring systems arent adequate to detect transient cardiac symptoms. For example, the Holter monitor has a less than 1% chance of detecting syncope events of four or more months apart, while a 30-day external loop recorder has less than a 25% chance, says Bob Thompson, MA, MS, clinical systems program manager for Medtronic, Inc., the medical technology company headquartered in Minneapolis that manufactures the device.

The ILR, on the other hand, has an 83 to 94% chance, he claims.

2. Consequence of not diagnosing and not treating the problem. Unexplained infrequent syncope not only forces patients to put their lives on hold by not being able to drive or work, but can also cause falls or other serious and, sometimes, fatal accidents.

3. Product description. Be sure to stress that the device is FDA-approved, since Medicare will not pay for investigational procedures, Swanson says.

4. Document current findings/status for the patient. Include complaints as well as the level of impairment. Detail how syncope has affected the patients life, such as changes in activities of daily living, she says.

5. Document chronological history of the patient. Note all syncope monitoring and testing efforts that have failed to provide a definitive diagnosis, she says. A time line may also be useful, she adds.

6. Recommend consideration of the ILR. Point out that the current clinical alternatives to the ILR are repetitions of the previous unsuccessful procedures, she says. Summarize the appropriateness of the diagnostic tool as well as its cost-effectiveness. Discuss the risks of implanting the system vs. the risks of not offering the device.

7. Describe the implant procedure. In addition to describing the surgery itself, also list the suggested CPT and diagnostic codes, such as syncope or near syncope, (780.2), she says. You may also want to attach a summary of relevant clinical articles, she adds.

8. Request coding clarification. Make sure that, in addition to requesting whether these are the correct codes to use for this first patient, that you also ask whether you need to again clarify the codes in subsequent patient cases, Swanson says.

More Coding Tips To Increase Payup of ILR 1. Check with your carrier for information on medical necessity as well as established medical policies. Ask the representative when the information will be posted. For example, the Georgia Medicare carrier says a policy will be posted on its Web site in about six months. 2. File a hard copy of the claim instead of an electronic one. (The electronic option doesnt allow you to attach supporting documentation such as copies of articles from peer-reviewed journals.) 3. Include a copy of the procedure report. 4. For removal of the device, use the same code as insertion: 33999 (Unlisted procedure, cardiac surgery). 5. For reading of the device, use one of the family of codes from 93268 -93272 (Patient demand single or multiple event recording with presymptom memory loop). 6. Variations on coding for reading the device may exist among payers. For example, if the patient has at least one or more recorded events, some payers may want you to use code 93799 (unlisted cardiovascular service or procedure). But if the patient has no recorded episodes during a 30-day period, no charge can be submitted. The practice will not be reimbursed. 7. You can bill for reading the device no more than once every 30 days. 8. It is possible that the global period for the insertion of the ILR is 90 days. Because there is no code for this new device, there is currently no global period assigned. But the global period for the external loop recorder is 90 days. Note: For more information on the ILR and its coding, call Medtronic at (888) 785-7962.