Primary Care Coding Alert

Family physicians may use one of several monitoring techniques to evaluate patients with possible cardiac arrhythmias, including long-term EKG monitoring and cardiac event monitoring. Each method is described by distinct sets of codes that distinguish between the type of equipment used and how the data are reported. Because the codes are similar, however, one set is often mistakenly reported when, in fact, another service has been provided.
 
According to Michelle Ashby, CRNP, who practices with The Heart Group in Lancaster, Pa., each modality gathers information about abnormal rhythms. One category monitors cardiac activity continuously, while the other is designed to record data only when cardiac symptoms occur. And, cardiac monitoring may be conducted over a short time (e.g., 24 hours) or during a longer time (e.g., 30 days). The final variable reflects how the data are reported to the physician: It may be transmitted electronically, or the patient may bring the monitoring device back to the office.

 
When a patient presents with indications like dizziness or giddiness (780.4), shortness of breath (786.05) or palpitations (785.1), family physicians may order long-term EKG recording to assess whether a cardiac condition is contributing to the symptoms. Sometimes referred to as Holter monitoring, long-term EKG monitoring provides a continuous record of the electrocardiographic activity of the patient's heart. "Patients are hooked up to a single-lead recorder for 24 or 48 hours and wear the monitor during their daily activities," Ashby says. At the end of the assessment period, patients return the monitor to the physician, and the recordings are reviewed in the office.
 
This type of continuous monitoring is reported with codes from the 93224-93233 series, although two methods are represented within the code family:
   
1. Superimposition scanning. Family physicians say they most frequently use procedures described in 93224-93227. Within this set, 93224 (electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation) is the global code, while each of the subsequent three codes describes components of the overall service, i.e., 93225, ... recording (includes hookup, recording, and disconnection); 93226, ... scanning analysis with report; and 93227, ... physician review and interpretation. These four codes are used to report services conducted by specially trained technicians who visually scan patient waveforms generated by the monitor. These are then compared with a normal waveform to identify discrepancies.
 
2. Microprocessor analysis. The second set of long-term EKG monitoring codes within the series 93230-93233 does not use superimposition scanning. Instead, a microprocessor analyzes the data and produces a printout of all recorded data in a miniaturized display. Again, 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) describes the comprehensive evaluation, while the other three codes represent component services.

 
A third recording mechanism may also be used. Codes 93235-93237 are similar to the previous two sets in that a long-term EKG monitor is worn for 24 or 48 hours. However, these studies require that patients indicate when they have symptoms. "The device features a button that patients push when something is going on -- for instance, if they experience a dizzy spell," Ashby says. "This event marker creates a record of the time when the symptom occurred." Technicians then pay closer attention to the time frame noted when the recording is returned to the office.
 
This type of monitoring is reported with global code 93235 (electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, physician review and interpretation) or component codes 93236 (... monitoring and real-time data analysis with report) and 93237  (... physician review and interpretation).

 
Coders must be certain not only to use the appropriate set of codes when reporting long-term EKG monitoring but also to ensure they are using the global and component codes correctly, says Mary Beth Loebl, CPC, senior consultant with Healthcare Consultants of America Inc., based in Augusta, Ga., and an accredited coding instructor by the American Academy of Professional Coders (AAPC).
     

Global codes versus component codes: "If the family practice hooks the patient up to the monitor and provides all of the recoding, analysis, review and interpretation, it should always report the first code in the series. Coders would assign component codes only if the practice performed either the technical (e.g., hooking the patient up to the monitor) or the professional services (e.g., interpreting the recording)."
 
It's not uncommon for coders mistakenly to report all three component codes to describe the comprehensive service. For instance, instead of reporting only code 93224, the practice might erroneously report 93225, 93226 and 93227. "However, when a global code is available, coders must use it," Loebl says.
     

Date of service: Because long-term EKG monitoring is usually initiated on one day and completed on another, coders may also be unsure which date of service be reported. Some payers require that tests should be reported on the day initiated, while others ask that the date of service reflect the completion date. While the American College of Cardiology recommends the latter because interpretation services can't occur until the test is concluded, coders should check with the insurer in question.

 
Although all of the relevant codes describe 24-hour monitoring, sometimes services may be provided for shorter or longer periods. Most payers indicate that monitoring of fewer than 12 hours will be regarded as a standard ECG service and reimbursed at rates corresponding to 93000 (electrocardiogram, routine ECG with at least 12 leads; with interpretation and report), 93005 (... tracing only, without interpretation and report) and 93010 (... interpretation and report only).
 
Payer policies vary when monitoring is performed over two or more consecutive days, i.e., 48-hour evaluation. In some cases, family practices may report each test date separately. Other insurers view long-term EKG monitoring as a complete service and do not allow the global code to be billed twice. In her experience, Loebl says, most practices bill the global code with modifier -22 (unusual procedural services) and two units of service to describe 48-hour monitoring. Other coding professionals say their payers require that the first date of service be represented with the global code (e.g., 93224), because both the technical (e.g., hookup) and professional services (e.g., reviewing and interpreting data generated that day) were performed.
 
Services provided the second day are reported with the professional component only (e.g., 93227) because the technical services were not repeated on that date. Coders should ask individual insurers which approach to apply.
 
Loebl also notes that many payers, including local Medicare carriers, regard long-term EKG codes as poten- tially overutilized. To combat this, they have detailed policies that outline acceptable diagnoses and guidelines for coverage. Family practitioners must keep abreast of appli- cable rules and document the need for monitoring carefully.

 
Cardiac event monitoring occurring over a longer time (up to 30 days) is most often used with patients recently discharged from the hospital following a cardiac event, e.g., myocardial infarction, 410.xx. It may also be used with patients whose symptoms are difficult to diagnose or occur too sporadically to be recorded by a long-term EKG monitor. 
   
"An event monitor, a small device worn on a belt or on the wrist like a watch, continuously reads cardiac activity," Ashby says. "When patients experience symptoms, they push a little button. The event recorder then stores the data reflecting cardiac activity several seconds prior to and following the onset of symptoms. Using a special cord, patients then plug the monitoring device into the phone and download the event record to the physician's office or a monitoring service. The office or service then prints out a rhythm strip for the physician to read."

 
As with long-term EKG monitoring, these cardiac event codes describe global and component services. While accepting CPT codes in certain circumstances, Medicare has also issued temporary Level II HCPCS codes for other situations, Loebl says. 
 
"Generally, HCPCS codes G0004-G0007 are used when providers of the service have the capability to receive and record transmissions 24 hours a day, every day of the year," Loebl explains. "This includes receipt of the ECG signal and voice transmission related to any symptoms. Transmissions must be received by a person capable of responding to the transmissions and not by an answering machine for review at a later time. In contrast, codes 93268-93272 do not require 24-hour attended monitoring."
 
She adds that the receiver of the transmission must be a technician, nurse or physician trained in ECG interpretation and abnormal rhythms, and that a physician must be available for immediate consultation 24 hours a day for transmission review in case of significant symptoms or ECG abnormalities. The 24-hour attended monitoring devices provide both presymptom memory loop and post-symptom recording.
 
The HCPCS codes have slightly different definitions:  

G0004 -- patient demand single or multiple event recording with presymptom memory loop and 24-hour attended monitoring, per 30-day period; includes transmission, physician review and interpretation;
     

G0005 -- ... recording (includes hookup, recording and disconnection);
          

G0006 -- ... 24-hour attended monitoring, receipt of transmissions, and analysis; and 

G0007 -- ... physician review and interpretation only.

 
Use these codes for billing private insurers:

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 hookup, recording and disconnection);
     

93271 -- ... monitoring, receipt of transmissions, and analysis; and
     

93272 -- ... physician review and interpretation only.
  
 
Loebl also notes that G0015 (postsymptom 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) are reported on some occasions: "G0015 and G0016 were developed for services in which the device used does not have the capability for presymptom memory loop recording." She says G0004-G0007 should not be billed with G0015-G0016 because devices used for the former services already include postsymptom recording.

 
Because family physicians often outsource longer monitoring services, coders must pay particular attention to these codes. The first code in the series (i.e., global codes 93268 or G0004) would be used only if the family practice provides all related services. If the practice uses an outside provider for portions of the service, it can report only the portions of the test it provides. For instance, if a monitoring service provided the hookup, monitoring and analysis for a privately insured patient, it would report 93270 and 93271. The family physician would report the review and interpretation with 93272.
 
"In some cases, however, the practice and the outside service will include specific billing instructions in their professional agreement," Ashby says. "The physician's office may bill the global code and subsequently pay the monitoring service. Coders must be familiar with the contracts in place."
 
Virtually all payers reimburse for these services once during any 30-day period no matter how many cardiac events occur. Frequency edits determine how often cardiac event monitoring may be billed, e.g., once every 180 days.