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© 2020 MedAxiom DO NOT DISTRIBUTE WITHOUT PERMISSION
Diagnostic Arrhythmia and Device MonitoringJammie Quimby, CPC, CCC, CEMC, CCS-P, CPMA, CRC, CDEO
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Coding CEU CertificatesCEU Certificates and Webcast Evaluations are only sent to those individuals that register for BOCN webcasts. Please make sure that each individual registers using their correct email address.• AAPC –
• Coding CEU Certificates will be emailed out to all registered attendees.
• Please give 5-7 business days• BMSC –
• For Coding CEUs, please email Joline to request at: [email protected]
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MedAxiom DisclaimerThis presentation is for general information purposes only and is not intended and does not constitute legal, reimbursement, coding, business or other advice. Furthermore, it is not intended to increase or maximize payment by any payer. Nothing in this presentation should be construed as a guarantee by MedAxiom regarding levels of reimbursement, payment or charge, or that reimbursement or other payment will be received. Similarly, nothing in this presentation should be viewed as instructions for selecting any particular code. The ultimate responsibility for coding and obtaining payment/reimbursement remains with the customer. This includes the responsibility for accuracy and veracity of all coding and claims submitted to third party payers. Also note that the information presented herein represents only one of many potential scenarios, based on the assumptions, variables and data presented. In addition, the customer should note that laws, regulations, coverage and coding policies are complex and updated frequently. Therefore, the customer should check with their local carriers or intermediaries often and should consult with legal counsel or a financial, coding or reimbursement specialist for any coding, reimbursement or billing questions or related issues. This information is for reference purposes only. It is not provided or authorized for marketing use.
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CPT® Disclaimer
CPT® copyright 2020 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association
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Cardiac Rhythm Management
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CMS Internet-Only Manual (IOM), Publication 100-02, Chapter 15, section 80.6.1 Requirements for Ordering and Following Orders for Diagnostic Tests which states:
“All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary
Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary".
Diagnostic Test Order(s)
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Signature Requirements
Requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or
an electronic signature. Stamp signatures are not acceptable.
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1 2 3 4
Interpreting a diagnostic test or
Performing a procedure
Includes indirect practice and malpractice expenses related to that work
Modifier -26 is used with the CPT code reported to indicate that only the professional service is being reported (unless the CPT is designated as a professional service only)
Represents the physicians work:
Professional Component (-26)
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Administrative Personnel and capital (equipment and facility) cost(s)
Modifier –TC is used with the reporting CPT code to indicate that only the technical component is being reported
Represents all “non-physician” work:
Technical Component (-TC)
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Supervision Guidelines
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‒ means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure
‒ in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed
‒ means a physician must be in attendance in the room during the performance of the procedure
General Direct Personal
Supervision Defined
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Procedure must be performed under the general supervision of a physician
Procedure must be performed under the direct supervision of a physician
Procedure must be performed under the personal supervision of a physician
Concept does not apply
Procedure is not a diagnostic test or procedure is a diagnostic test that is not subject to the physician supervision policy
Levels of Physician Supervision
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0
01
02
03
09
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Example of Supervision Requirements for Pacemakers
• 01 – General • 02 – Direct • 09 – Concept does not apply
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• Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under §1861(r) of the Act.
• They may not function as supervisory physicians under the diagnostic tests benefit (§1861(s)(3) of the Act).
• These practitioners may personally perform diagnostic tests as provided under §1861(s)(2)(K) of the Act, §1861(s)(3.
• May perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration.
NPP Services
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Example of General Supervision
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Example of Direct Supervision
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Arrhythmia Testing
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Ambulatory Monitors
• Small, portable electrocardiograph machines that are able to record the heart’s rhythm
• Each type of monitor has unique features related to length of recording time and ability to send the recordings
EKG – see what’s happening in a 30
second strip
Holter – continuously record up to 48 hours
of beat per beat information
Event monitors –record over a longer period of time, most
typically up to 30 days, but not continuously
with the ability to transmit info, but not
automatically
MCOT – continual monitoring and under
24/7 attended surveillance with ability to auto transmit based
on arrhythmia detection
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EKG’s / ECG’s
• A simple, noninvasive procedure that checks for signs of heart disease. It’s a test that records the electrical activity of your heart through small electrode patches that a technician attaches to the skin of your chest, arms and legs
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• 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report– 93005 tracing only, without
interpretation and report– 93010 interpretation and report
only
• 93040 Rhythm ECG, 1-3 leads; with interpretation and report– 93041 tracing only, without
interpretation and report– 93042 interpretation and report
only
CPT Reporting – EKG’s / ECG’s
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Holter Monitor
• A small, portable, battery-powered ECG machine worn by a person to record heartbeats on tape over a period of 24 to 48 hours during normal activities
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CPT Reporting – Holter Monitor
• 93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation − 93225 recording (includes connection, recording, and disconnection)− 93226 scanning analysis with report− 93227 physician review and interpretation
(For less than 12 hours of continuous recording, use modifier 52)(For greater than 48 hours of monitoring, see Category III codes 0295T-0298T)
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CPT Reporting – Zio Patch Monitor• 0295T External electrocardiographic recording for more than 48 hours
up to 21 days by continuous rhythm recording, scanning analysis with report, review and interpretation− 0296T recording (includes connection and initial recording)− 0297T – scanning analysis with report− 0298T – review and report − These codes can NOT be reported in conjunction with the Holter
series codes (93224-93227)
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Event Monitor
• A cardiac event monitor is a battery-powered portable device that a patient can control to tape/record their heart’s electrical activity (ECG) when they are having symptoms
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CPT Reporting – Event Monitor
• 93268 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring: includes transmission, physician review and interpretation
• 93270 recording • 93271 transmission and analysis• 93272 review and interpretation by a physician or other qualified health care
professional(For implanted patient activated cardiac event recording, see 33285, 93285, 93291, 93298)
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Mobile Cardiac Outpatient Telemetry (MCOT) Monitor• MCOT monitoring automatically detects
and transmits cardiac abnormalities via cell phone in real time to a diagnostic laboratory.
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• 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
• (Report 93228 only once per 30 days)(Do not report 93228 in conjunction with 93224, 93227)
• 93229 technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
• (Report 93229 only once per 30 days)
• (Do not report 93229 in conjunction with 93224, 93226)
(For external cardiovascular monitors that do not perform automatic ECG triggered transmissions to an attended surveillance center, see 93224-93227, 93268-93272)
CPT Reporting – MCOT
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The patient complains of palpitations, and physical examination and standard EKG have not satisfactorily explained the patient's complaints.
The patient has experienced an unexplained syncopal episode or the patient has experienced a transient episode of cerebral ischemia which is felt to possibly be secondary to a cardiac rhythm disturbance.
Complete Heart BlockSecond Degree AV BlockNew Left Bundle Branch BlockNew Right Bundle Branch BlockBifasicicular BlockParoxysmal SVTParoxysmal VTAtrial Fib/FlutterVentricular Fib/FlutterCardiac ArrestSA Node DysfunctionFrequent PAC'sFrequent PVC'sWandering Atrial PacemakerUnspecified Cardiac Arrhythmia
Dressler's SyndromeHistory of Myocardial InfarctionAngina PectorisPrinzmetals's AnginaAneurysm of Heart WallChronic Ischemic Heart DiseasePericarditisMitral Valve DiseaseCardiomyopathyAnomalous AV ExcitationCardiomegalyPost Heart SurgeryProlonged QT Interval
Symptoms Diagnosed w/ Arrhythmia or Conduction Disorder Diagnosed w/ heart condition
Local Coverage Determination (L33380) – FCSO 1. Non-Activated Continuous Recorders
LCD Example
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1 2 3
When indicated for the detection, characterization, and documentation of symptomatic transient arrhythmias, when the frequency of the symptoms is limited and use of a 24-hour ambulatory EKG is unlikely to capture and document the arrhythmia
The patient has undergone a complete history and physical by a physician prior to the initiation of monitoring. The history and physical must indicate that the patient is experiencing recurrent, transient symptoms suggestive of cardiac arrhythmia Note: Palpitations are extremely common in healthy individuals. Therefore, if palpitations is billed as the diagnosis supporting medical necessity, the history and physical or other pertinent medical record documentation must support the presence of associated symptoms such as dizziness, shortness of breath, chest discomfort, or an underlying history of cardiac disease; and
A physician overseeing the medical management of the patient orders the medically necessary patient demand event recorder.
Any device used for event recording must be FDA approved for the indication for which it is being utilized.
The FDA approved device must be capable of transmitting EKG leads I, II, or III (the standard limb leads).
Will be considered medically reasonable and necessary:
A definitive diagnosis has not been made after all of the following
conditions have been met:
The patient has undergone a 12 lead EKG and rhythm strip:
Local Coverage Determination (L33380) – FCSO 2. Patient / Event-Activated Intermittent Recorders
LCD Example
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1 2 3
No more than one 48 hour WEM service would be expected in a 6 month period
No more than one 30 day WEM service would be expected in a 6 month period
Use of WEM more frequently than at 6 month intervals requires physician documentation in the progress notes specifically supporting the medical necessity of a more frequent interval
Local Coverage Determination (L33380) – FCSOLimitations:
LCD Example
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Cardiac Devices
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PM – Single, Dual, Multi System(s)→ A small electronic device that is implanted to
help control abnormal heart rhythms→ Delivers pacing pulses and stores data about
arrhythmias detected and the device’s response
→ A small implantable device that sends electrical pulses to the heart whenever it senses that the heartbeat is too slow
→ Leadless pacing devices are placed directly in the heart without the need for a surgical pocket and insulated wires (called leads)
Traditional Pacemaker (PM) Leadless Pacemaker
Pacemaker
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ICD – Single, Dual, Multi System(s)→ Treats rapid heart rates such as ventricular
tachycardia (VT) and ventricular fibrillation (VF)
→ Delivers pacing signals and shocks, as needed
→ Stores data about arrhythmia’s detected and the device’s response to that arrhythmia
→ ICD sits outside ribcage→ No connection to interior
of heart→ Lead tunneled under skin, along the bottom
of the ribcage and breastbone→ Lead does not touch heart
Implantable Defibrillator (ICD) Subcutaneous Implantable Defibrillator (SICD)
Defibrillator
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A pacemaker or implantable defibrillator with pacing and sensing function in only one chamber of the heart or a subcutaneous electrode
A pacemaker or implantable defibrillator with pacing and sensing function in only two chambers of the heart
A pacemaker or implantable defibrillator with pacing and sensing function in three or more chambers of the heart
Single Lead Dual Lead Multiple Lead
Lead(s) – Defined
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→ An implantable CV device used to assist in management of non-rhythm related cardiac conditions
→ Collects physiologic CV data elements from one or more internal sensors (such as RV pressure, PA pressure, LA pressure, or an index of lung water) and/or external sensors (such as BP or body weight)
→ A subcutaneously placed device that continuously records the electrocardiography rhythm, triggered automatically by rapid, irregular and/or slow heart rates or by the patient during a symptomatic episode
Implantable Cardiovascular Monitor (ICM)
Subcutaneous Cardiac Rhythm Monitor (ILR)
Other Systems
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In-Person Interrogation and In-Person Programming Services
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Interrogation(s) Defined
• An evaluation of an implantable device• Stored details are retrieved• The retrieved information is evaluated to determine the current
programming of the device
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ü Programmed Parametersü Lead(s)ü Batteryü Capture & Sensing Functionü Heart Rhythm
ü Programmed Parametersü Lead(s)ü Batteryü Capture & Sensing Functionü Presence or Absence of
therapy for V-Tach & underlying Heart Rhythm
ü Programmed Parameters & analysis of at least one recorded physiologic cardiovascular data element from either internal or external sensors
PM ICD ICM
ü Programmed Parameters & Heart Rhythm during recorded episode(s);
o Both patient initiated and device algorithm detected events, when present
ILR
Components of an In-Person Interrogation
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93288
Pacemaker or Leadless PM
93289
Defibrillator
93261
Implantable Subcutaneous
Defibrillator
93290
Implantable Cardiovascular Monitor (ICM)
93291
Subcutaneous Cardiac Rhythm
Monitor (ILR)
In-Person Interrogation CPT Code(s)
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CPT Reporting Instructions
• Reported per procedure• May not be reported with programming on the same date of
service• May not be reported with remote interrogation services
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Programming Evaluations
Programming evaluations are
significantly more work than an interrogation
evaluations
These are billable within the remote time
frame
The code is chosen based on the number of
leads/chambers –with each lead
checked there is more work involved
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ü Programmed Parametersü Lead(s)ü Batteryü Capture & Sensing Functionü Heart Rhythmü Sensor Rate Responseü Lower & Upper Heart Ratesü AV Intervalsü Pacing Voltage & Pulse Durationü Sensing Valueü Diagnostics
ü Programmed Parametersü Lead(s)ü Batteryü Capture & Sensing Functionü Presence or Absence of therapy for V-Tach &
underlying Heart Rhythmü Sensor Rate Responseü Lower & Upper Heart Ratesü AV Intervalsü Pacing Voltage & Pulse Durationü Sensing Valueü Diagnostics
ü Programmed Parameters & Heart Rhythm during recorded episode(s);
o Both patient initiated and device algorithm detected events
ü Tachy and Brady detection criteria can be adjusted, if needed
Pacemaker Defibrillator Subcutaneous Cardiac Rhythm Monitor
Components of a Programming Device Evaluations
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Single Lead – 93279 (includes leadless)Dual Lead – 93280Multi Lead – 93281
Pacemaker
Single Lead – 93282Dual Lead – 93283Multi Lead – 93284
Defibrillator
93260
Implantable Subcutaneous
Defibrillator
93285
Subcutaneous Cardiac Rhythm Monitor
Programming CPT Code(s)
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Programming Service Periods “The Rules”
• Billed according to number of lead(s)/chambers• No service period (reported per procedure)• Billable within remote or telephone service period• Does not require that a setting be reprogrammed • Can only be done in person• Your physicians and device techs must understand and make
the distinction between interrogation evals and programming evals
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Interrogation vs Programming
üWe are actually interacting with the deviceüWe’re not just dumping its dataüWe are making adjustments….. to help find the most appropriate
settings üWe may decide to leave it right where it was – it can still be a
programming evaluation even if we do not reprogram the device
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CPT Guidance on In-Person Interrogation vs Programming
Often, but not always, these components will be adjusted
during a programming evaluation. The final programmed parameters
may or may not change after evaluation.
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Remote Device Services
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ü Programmed Parametersü Lead(s)ü Batteryü Capture & Sensing Functionü Heart Rhythm
ü Programmed Parametersü Lead(s)ü Batteryü Capture & Sensing Functionü Presence or Absence of
therapy for V-Tach & underlying Heart Rhythm
ü Programmed Parameters & analysis of at least one recorded physiologic cardiovascular data element from either internal or external sensors
PM ICD ICM
ü Programmed Parameters & Heart Rhythm during recorded episode(s);
o Both patient initiated and device algorithm detected events, when present
ILR
Components of a Remote Interrogation
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1 2
Remote Services
• Includes receipt of transmissions
• Technician review• Technical support• Distribution of results
• Analysis of data elements• Review• Report by physician or APP
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TECHNICAL PROFESSIONAL
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Professional 93294
Technical 93296
Pacemaker (includes leadless)
Professional 93295
Technical 93296
Defibrillator
Professional 93295
Technical 93296
Implantable Subcutaneous
Defibrillator
Professional 93297
Technical G2066
Implantable Cardiovascular Monitor (ICM)
Professional 93298
Technical G2066
Subcutaneous Cardiac Rhythm
Monitor (ILR)
Remote CPT Code(s)
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An interrogation is an interrogation whether it’s in-person or remote
Once a remote interrogation has been billed – any in-person interrogations performed within the 90 day period are not separately billable
CPT has language to say not to report if the monitoring period is less than 30 days
90 day service period applies to remote device interrogation services
Remote Interrogation Service Period
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Note there is a service period here too – but this one is 30 days not 90 days
Does have a minimum 10 day wording in CPT
Information will most likely be used in CHF management –CHF, Pulmonary HTN, etc.
Remote ICM Service Period
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Remote is billable once per 30 days
In-person interrogation not billable in the remote 30 day service period
In-person programming is separately billable in 30 day service period
CPT does have a minimum 10 day language
Remote ILR Service Periods
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Telephonic Pacemaker Services
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Transtelephonic rhythm strip pacemaker evaluation: “Service of transmission of an electrocardiographic rhythm strip over the telephone by the patient using a transmitter and recorded by a receiving location using a receiver/recorder (also commonly known as transtelephonic pacemaker monitoring).” • The electrocardiographic rhythm strip is recorded both with and without a magnet applied
over the pacemaker. The rhythm strip is evaluated for heart rate and rhythm, atrial and ventricular capture (if observed) and atrial and ventricular sensing (if observed). In addition, the battery status of the pacemaker is determined by measurement of the paced rate on the electrocardiographic rhythm strip recorded with the magnet applied.
Telephonic Service – 93293
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Telephonic Services
• NO ICD checks over the phone – just a pacemaker • Information obtained is more limited than a remote
interrogation• 93293 PM Phone check, with & w/out magnet app, physician
analysis, review/report, up to 90 days - single/dual/multi
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Telephone Service Periods
Telephonic services carry a 90 day service period
In-person interrogations as well as programming evaluations are billable in the telephone 90 day service period
30 day minimum
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Periprocedural Services
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Peri-procedural Pacemaker –eval & program of device before or after a surgery, procedure, or test – single/dual/multi/leadless
Peri-procedural ICD – eval & program of device before or after a surgery, procedure, or test – single/dual/multi
93286 93287
Peri-Procedural Device Evaluation and Programming
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Peri-Procedural Definition
If one provider performs the pre-surgical service and a separate provider performs the post-surgical service, each reports only one time.
If one provider performs both the pre- and post- evaluation and programming service, theappropriate code, would be reported two times.
Programmed before to settings appropriate for the surgery, procedure, or test, as required.A second evaluation and programming are performed after the surgery, procedure,.
The device system data are interrogated to evaluate the lead (s), sensor (s), and battery in addition to review of stored information, including patient and system measurements.
Peri-Procedural Device Evaluation & Programming: “PM or ICD to adjust the device to settings appropriate for the patient prior to a surgery, procedure, or test.”
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Some FAQ’s
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Revised and Released 2/1/19
Cardiovascular Monitoring Services
There are many different procedure codes that represent the cardiovascular monitoring services. These can be identified as professional components, technical components, or a combination of the two.
Some of these monitoring services may take place at a single point in time, others may take place over 24 or 48 hours, or over a 30-day period.
The determination of the date of service is based on the description of the procedure code and the time listed.
When the service includes a physician review and/or interpretation and report, the date of service is the date the physician completes that activity.
If the service is a technical service, the date of service is the date the monitoring concludes based on the description of the service.
For example, if the description of the procedure code includes 30 days of monitoring and a physician interpretation and report, then the date of service will be no earlier than the 30th day of monitoring and will be the date the physician completed the professional component of the service.
CMS
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE17023.pd
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Vendor FAQRemote monitoring is paid based on an episode of care. That episode is described as a period of 90 days for PMs and ICDs, and a period of 30 days for ICMs and ILRs. The episode is not billed until after the 90 or 30 days is completed, and the date of service should reflect the episode, not an individual professional review of a transmission. Providers need to check with local MACs or private payers to establish what date of service is required
Dates of Service
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FREQUENTLY ASKED QUESTIONS –
No. CMS diagnostic testing rules state that the supervisor must be a physician. If an APP performs the service, they may bill the service with his/her own billing number, provided state licensure allows it. The APP may NOT supervise a technician, nurse, or other office staff for the physician.
May an APP serve as a supervisor for monitoring services?
6666
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FREQUENTLY ASKED QUESTIONS –
If there is a separate and distinct medical reason for the E/M encounter, yes. For example, if a patient with a single chamber ICD, comes in for a device interrogation and presents with signs and symptoms not associated with the device check the E/M service and the device interrogation may be reported.
Is it permissible to bill an office visit (E/M codes) and a device interrogation during the same patient encounter?
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FREQUENTLY ASKED QUESTIONS –
Yes, you may bill for device interrogation services during the surgical global period. Diagnostic services are not part of the global surgical package.
Can we bill for device monitoring services during the surgical global period?”
6868
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CMS Manuals –instructions for administration of the Medicare program.
Google – WITH CAUTION
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What Guidance do I Follow?
Reference versus Rules versus Guidance
State MACsBe skeptical – trace the hierarchy of authority
Coders –Compliance Officers – etc. are not attorneys or judges or CMS
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Key Take-Aways
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Documentation Requirements
There are not set standards for device check report format or content:ü ACC representatives indicated that an electronic or hard copy report must be maintained
by the practice (downloaded if internet‐based)ü Audit experience has confirmed that a physician order and signature is critical.ü Proof that iterative adjustments were performed should be evident: threshold and
sensitivity measurements.ü Indication for the test (routine vs. triggered) should be documented in the available
documentation.
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Define processes and schedules to meet defined timeframes
If you provide an in-person interrogation inside the remote service period, it is not separately billable
If you do the technical component – remember to submit the technical code as well as the professional
Don’t forget about multi-function devices (ICMs)
Programming does not always equal adjustments – actually interacting with the device
Top 5 Revenue Cycle Tips
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ü Z95.0 – Used for periodic routine evaluations
ü Z45.018 – Used for reprogramming/adjustments
ü Z95.810 – Used for periodic routine evaluations
ü Z45.02 – Used for reprogramming/adjustments
ü Z95.818 – Used for periodic routine evaluations
ü Z45.09 – Used for reprogramming/adjustments
Pacemaker Defibrillator Other Systems
If a patient is having a device monitoring service and is asymptomatic with no abnormal findings documented, these are the ICD-10-CM code(s) reported:
DEVICE MONITORING ICD-10-CM
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Resources
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• https://gov.ecfr.io/cgi-bin/ECFR• https://www.federalregister.gov/• https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/index.html?redirect=/manuals/
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Q&AJammie Quimby, CPC, CCC, CEMC, CCS-P, CPMA, CRC, CDEORevenue Cycle Solutions [email protected]
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