Cardiology Coding Alert

Conquer your 93279-93285 fears by putting authoritative guidelines on your side.

CPT 2009 is a whole new world for device monitoring, but if you know how to approach the onslaught of new CPT guidelines available, you’ll learn the ropes in no time.

Master your terms: To understand the new “Cardiovascular Device Monitoring -- Implantable and Wearable Devices” section of CPT (93279-93299), you have to be sure your understanding of several terms matches CPT’s. For example, to choose among the new code families (consider a family to be a code set with a common start to their descriptors) you will need to distinguish concepts such as programming and interrogation. But within the family itself, you will need to make even more distinctions, such as which technology is involved.

Cardiology Coding Alert will cover all the new codes in the coming months and will begin by discussing 93279-93285 below.

Eliminate the ‘Reprogramming’ Concept for 2009

Start here: The first code family is 93279-93285 (Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with physician analysis, review and report …)

Key point: You need to pay close attention to the definition of programming for 2009 codes, according to Bruce Wilkoff, MD, FACC, co-presenter of the “ACC/MedAxiom Webinar on New 2009 CPT Codes for Cardiac Device Monitoring” (http://qualityfirst.acc.org/advocacy/Pages/CDMonitoringWebinar.aspx). Wilkoff is director of cardiac pacing and tachyarrhythmia devices for the Cleveland Clinic.

Here’s why: Many 2008 codes were separated by whether they involved reprogramming. But you won’t see the term “reprogramming” in the 2009 codes.

For example: Consider the following 2008 codes:

• 93734 -- Electronic analysis of single chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming

• 93735 -- … with reprogramming.

Proving that there’s no easy code-for-code crosswalk from 2008 to 2009 monitoring codes, CPT crosses both 93734 (without reprogramming) and 93735 (with reprogramming) to all of the following (emphasis added):

• 93279 -- Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with physician analysis, review and report; single lead pacemaker system

• 93288 --  Inerrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system

• 93294 -- Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system with interim physician analysis, review(s) and report(s).

Solution: Apply CPT’s ‘Programming’ Definition

What to do: CPT guidelines offer specific definitions to help you apply the new codes and decide when a programming code is appropriate.

Function evaluation: You should apply a programming code when the operator evaluates all of the following device functions (if present): battery, programmable settings, and lead(s).

Adjustments: As part of the programming evaluation, the provider also conducts iterative adjustments (such as progressive pacing output changes of a pacing lead, according to CPT). These adjustments allow the provider to assess and choose the final program parameters.

As Wilkoff pointed out in the Webinar, whether the final parameters are the same as the starting parameters doesn’t matter. You can still report a programming code (assuming you meet the other CPT requirements).

Required Components Aren’t 1 Size Fits All

Each device type (pacemaker, implantable cardioverter-defibrillator, implantable loop recorder) has a separate set of required components the provider must evaluate for programming, as CPT guidelines spell out.

For example, for a pacemaker, CPT requires these

components:

• programmed parameters

• lead(s)

• battery

• capture and sensing function

• heart rhythm.

The guidelines state that “often, but not always,” a pacemaker programming evaluation may include adjustments of these components:

• sensor rate response

• lower and upper heart rates

• AV intervals

• pacing voltage and pulse duration

• sensing value

• diagnostics.

Helpful: You should find that the majority of inperson services will satisfy the definition of the programming evaluation codes. “Especially for patients being remotely monitored, doctors will not typically bring the patient into the office for an evaluation unless they are going to perform the CPT-defined programming evaluation. Many doctors will equate this to a ‘threshold check’” says Jim Collins, CCC, CPC, ACS-CA, CHCC, president of CardiologyCoder.Com, Inc.

Be sure your staff understands your new documentation needs so there’s no confusion over whether the team provided an actual programming evaluation service.

Narrow Coding Choices by Device

Pinpointing device type and meeting required components described above is key to correct coding because the programming codes are divided by device type.

Pacemaker: You have three pacemaker codes:

• 93279 -- single lead pacemaker system

• 93280 -- dual lead pacemaker system

• 93281 -- multiple lead pacemaker system.

According to CPT guidelines, a pacemaker is “an implantable device that provides low-energy localized stimulation to one or more chambers of the heart to initiate contraction in that chamber.”

ICD: You also have three implantable cardioverterdefibrillator (ICD) codes:

• 93282 -- single lead implantable cardioverterdefibrillator system

• 93283 -- dual lead implantable cardioverterdefibrillator system

• 93284 -- multiple lead implantable cardioverterdefibrillator system.

An ICD is an implantable device that performs all of the functions of a pacemaker but is also capable of delivering a shock to the patient’s heart to respond to ventricular tachycardia, ventricular fibrillation, or sudden cardiac death, says Collins.

Both pacemakers and defibrillators also may have the ability to monitor and record physiologic data (non-ECG derived data: respiratory rate, lung water volume, blood pressure, weight). When used to perform this monitoring/recording, the device is considered to be an implantable cardiovascular monitor (ICM) as well as a pacemaker or defibrillator. The distinction between physiologic data and ECG derived data is important because you are allowed to bill for both even if the two data types are captured on the same device, Collins says.

ILR: Your final programming evaluation choice in this code family is 93285 (... implantable loop recorder system). An implantable loop recorder (ILR) records the electrocardiographic rhythm triggered either automatically by a heart rate change (fast or slow) or by the patient during an episode.

Take note: The AMA corrected the note following 93285. As originally printed in AMA CPT manuals, the note says, “Do not report 93285 in conjunction with 33282, 93279, 93284, 93291)” (emphasis added). The corrected version changes the bolded section to “93279-93284.” In other words, don’t report 93285 (ILR interrogation) with any of the codes between 93279 and 93284 (the entire family of in-person programming evaluations that is the focus of this article).

Swap Chambers for Leads in 2009

The pacemaker and ICD descriptors include the terms “single lead, “dual lead,” and “multiple lead.”

Careful: CPT differentiates both the pacemaker and ICD programming evaluation codes by the number of heart chambers the device offers pacing and sensing function in, so be sure you choose your code based on the chambers rather than number of electrodes. According to CPT definitions:

• single lead = one chamber

• dual lead = two chambers

• multiple lead device = “three or more” (which in practical application means “three or four”) chambers.

Note that the Heart Rhythm Society states that a multiple lead device code is appropriate for three or more active leads in a biventricular device, but if there are two leads (biventricular system with no atrial lead), the dual lead codes are appropriate (www.hrsonline.org/Policy/CodingReimbursement/coding/upload/FAQs_2009DeviceMonitoring.pdf).

Resource: Want more information? Check out the audioseminar “2009 Cardiology Update,” presented by Jim Collins, CCC, CPC, ACS-CA, CHCC, president of CardiologyCoder.Com.