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 [...]