Cardiology Coding Alert

Event monitors often are used by cardiologists to track a patients heart condition. Billing for this service has been confusing because CPT lacked specific codes and Medicare and private payers have differing coding requirements. By using new codes included in CPT 2000 and drawing clear lines between Medicare and other payers, cardiologists can ensure proper reimbursement when providing monitoring services.

Until recently, there were no codes for implantable loop recorders (ILR), and cardiologists often were confused about using the unlisted code (33999) for these devices. But CPT 2000 includes three new codes for this type of event monitor that will facilitate billing for it.

The three new implantable loop codes are:

33282implantation of patient-activated cardiac event recorder
33284removal of an implantable, patient-activated cardiac event recorder
93727electronic analysis of implantable loop recorder (ILR) system (includes retrieval of recorded and stored ECG data, physician review and interpretation of retrieved ECG data and reprogramming).

The loop recorder is implanted subcutaneously in the left pectoral region and must be removed when it is no longer clinically necessary or when its battery runs out, which happens after approximately 14 months. To date, the only such device with FDA approval is the Medtronic Reveal ILR, says Sueanne Bicknell, RRA, CPC, CCS-P, compliance administrator for CPR-Heart Place, a group practice with 65 cardiologists in Dallas.

The recorder is placed under the skin, similar to a pacemaker, and remains there. Implanting the recorder is an outpatient procedure; typically, the patient will return two weeks later so the cardiologist can test the device in his or her office.

Coding and billing points cardiologists should note regarding ILRs include:

1. Medicare limits the use of these devices to one diagnosissyncope (780.2).

2. The 93727 code includes not only reprogramming but also any subsequent evaluation.

3. There are not time limits on billing for return visits to the doctor after the ILR is implanted, as is the case with some other event monitors that restrict cardiologists to billing only once every 30 days. When the device is implanted, however, the first 90 days that follow are part of that procedures global period.

4. Any electrophysiological testing performed before the ILR is implanted should be coded and paid separately.

5. No surgery assist is allowed to be billed for implant or removal.

6. Removing an ILR on the same day you put in a pacemaker implant is inclusive and will not be paid separately.

7. Medicare will pay for only one ILR every two years.

8. Any evaluation and management (E/M) visits on the same day as a 93727 to test the device must be billed with modifier -25 (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that a significant or separately identifiable service was rendered.

Coding Other Event Monitors

1. Post-Symptom Recorder. This device is not attached to the patient's chest. It does not record constantly and it has no memory. When the patient experiences rapid heartbeats, he puts electrodes on his fingers or wrists and dials a telephone number. The cardiac event is traced on the other end of the line and sent to the physician for review and interpretation.

This service is reported to private carriers using CPT codes 93012 (telephonic transmission of post-symptom electrocardiogram rhythm strip[s], per 30 day period of time; tracing only) and 93014 (physician review with interpretation and report only). For Medicare patients, cardiologists should use HCPCS codes G0015 (post-symptom telephonic transmission of electrocardiogram rhythm strip[s] and 24-hour attended monitoring, per 30-day period; tracing only) and G0016 (physician review and interpretation only).

Several transmissions may be done, which is why the 30-day time period was established, Bicknell says. Billing is allowable and reimbursed for this procedure only once every 30 days regardless of whether one transmission or 20 is done within that time.

If the physician or clinic owns the event recorder, 93012 is billed for tracing and 93014 for the interpretation of a non-Medicare patient. Medicare patients, meanwhile, are billed using G0015 for tracing and G0016 for the interpretation. If the physician or clinic leases the equipmenta significant distinction for Medicareonly G0016 should be billed because Medicare will not pay for tracing on recorders that are leased. With private carriers, both 93012 and 93014 may be billed in this situation.

2. Loop Recorders. These devices are pre-symptom recorders. The patient does not have to activate the monitor to begin recording because the monitor continuously records the patients heart rhythm. For private payers 93268 (patient demand single or multiple event recording with presymptom memory loop, per 30 day period of time; includes transmission, physician review and interpretation), 93270 (recording [includes hook-up, recording, and disconnection), 93271 (monitoring, receipt of transmissions, and analysis) and 93272 (physician review and interpretation only) are used. For Medicare patients, the corresponding HCPCS codes are G0004-G0007.

If the physician/clinic owns the loop recorder, 93268 should be billed for the hookup, recording, transmission and interpretation to non-Medicare payers, while G0004 is used for Medicare patients. If the physician or clinic leases the equipment, Medicare is billed using G0005 (hookup and recording) and G0007 (interpretation). As with the post-symptom recorders, Medicare will not pay for tracing (G0006) if the physician or clinic does not own the equipment.

3. Holter Monitors. This device continuously records the patients statistics for 24 hours. Cardiologists should not use G-codes for Medicare patients on Holter monitors. Their use is reported to both Medicare and private payers using codes 93230 (electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation); 93231 (recording [includes hook-up, recording, and disconnection); 99232 (microprocessor-based analysis with report) and 99233 (physician review and interpretation). With the Holter monitor, cardiologists may bill more than one monitoring per month.

Stay Aware of Monitor Being Used

Clinics and technicians should be aware of which type of monitor is being used and whether it is leased or owned, Bicknell says. An event recorder such as a Holter monitor is just thatit records the specific eventand is activated by the patient. On the other hand, a loop recorder uses a memory loop to continuously monitor the patient, regardless of whether he or she is experiencing a cardiac event.

If a clinic owns its Holter monitors but leases its event and loop monitors, miscoding (especially to Medicare) is likely to follow if the ownership of the monitors is confused. Consequently, the clinic must maintain a record of the source of its monitoring equipment.

In addition, billing for event monitoring services should not begin until the test is completed and the interpretation and report are done, Bicknell says.