Diagnostic Arrhythmia and Device Monitoring...capture and document the arrhythmia The patient has undergone a complete history and physical by a physician prior to the initiation of

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Diagnostic Arrhythmia and Device MonitoringJammie Quimby, CPC, CCC, CEMC, CCS-P, CPMA, CRC, CDEO


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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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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.


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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1 2 3

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)

10


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


Example of Supervision Requirements for Pacemakers

• 01 – General • 02 – Direct • 09 – Concept does not apply


• 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


• 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


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)


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)


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


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)


Mobile Cardiac Outpatient Telemetry (MCOT) Monitor• MCOT monitoring automatically detects

and transmits cardiac abnormalities via cell phone in real time to a diagnostic laboratory.


• 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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1 2 3

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


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


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


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


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


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


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


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


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.


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


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

51

TECHNICAL PROFESSIONAL


Professional 93294

Technical 93296

Pacemaker (includes leadless)

Professional 93295

Technical 93296

Defibrillator

Professional 93295

Technical 93296


Defibrillator

Professional 93297

Technical G2066


Professional 93298

Technical G2066

Subcutaneous Cardiac Rhythm

Monitor (ILR)

Remote CPT Code(s)

52


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

53


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


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.”

6262


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


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


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



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?

6767



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


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


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.


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





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/


Q&AJammie Quimby, CPC, CCC, CEMC, CCS-P, CPMA, CRC, CDEORevenue Cycle Solutions [email protected]

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Documents

Diagnostic Arrhythmia and Device Monitoring...capture and document the arrhythmia The patient has undergone a complete history and physical by a physician prior to the initiation of