Cardiac Event Detection Monitoring

Article Title

Cardiac Event Detection Monitoring - 4C-56AB-R4

Contractor’s Determination Number

4C-56AB

Contractor Name

TrailBlazer Health Enterprises

Contractor Number

04001 (04101, 04201, 04301, 04401, 04901).
04002 (04102, 04202, 04302, 04402).

Contractor Type

MAC – Part A.
MAC – Part B.

AMA CPT/ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Indian Health Service.
End Stage Renal Disease (ESRD) facilities.
Skilled Nursing Facilities (SNFs).
Rural Health Clinics (RHCs).

Transitioned WPS legacy providers.

Oversight Region

Region IV.
Region VI.

Original Article Effective Date

03/01/2008

03/21/2008

06/13/2008

Article Revision Effective Date

01/01/2011

Article Ending Effective Date

N/A

Article Text

Abstract

Cardiac Event Detection involves the use of a long-term monitor by patients to document a suspected or paroxysmal dysrhythmia. Following the recording of events, the patient transmits data via telephone to a physician’s office or a specified station that is equipped and staffed to assess electrocardiographic data and to initiate appropriate management action. The device must be patient-activated.

Part A Program Instructions:

Reasons for Denial

Cardiac Event Detection services using an answering service or answering machine as the receiving station is not covered.
Cardiac Event Detection that is not 24 hours a day, seven days a week attended is not separately payable. Such services have been described as the “King of Hearts,” “Event Monitor” and “Transtelephonic Arrhythmia Monitoring.” These services are not payable by Medicare.
Systems utilizing computers to dial the physician’s office so the physician receives transmission by way of a relay is not a covered service since there is no attendance.
Cardiac Event Detection is not covered for any patient who is unresponsive, comatose, severely confused or otherwise unable to recognize symptoms or activate the recorder.
Cardiac Event Detection is not covered for outpatient monitoring of recently discharged postinfarct patients.
“Routine” continued monitoring in the absence of treatable symptoms is considered screening and is not medically necessary.
All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD.
Service(s) rendered is not consistent with accepted standards of medical practice.
The medical record does not verify that the service described by the CPT/HCPCS code was provided.
The service does not follow the guidelines of the related LCD.
The service is considered:

Investigational.
For routine screening.
A program exclusion.
Otherwise not covered.
Never medically necessary.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.
Cardiac event monitoring must be 24 hours a day, seven days a week attended for reimbursement.
Cardiac Event Detection involves the long-term monitoring of patients to document a suspected or paroxysmal dysrhythmia. Therefore, it is considered medically unnecessary to utilize a Cardiac Event Detection service in place of a standard Electrocardiogram (ECG) or ECG rhythm strip. If it is necessary to transmit an ECG or ECG rhythm strip to another location for interpretation/report, then a standard ECG or ECG rhythm strip should be recorded and faxed to the interpreting physician. Only the ECG or ECG rhythm strip code may be billed.
All listed services are payable in an office (11) setting. Outpatient hospital settings and clinics (22) are additional payable places of service for physician review and interpretation (CPT code 93272). Home (12) and nursing facility settings (31, 32 and 33) are additional appropriate places of service for the hook-up of the monitor (CPT code 93270). Services to hospital inpatients are not reimbursable. Technical components of services to patients in a Part A SNF stay are not separately billable.
CPT codes 93268 and 93270 are Non-OPPS only codes.
Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service.
To report these services, use the appropriate HCPCS or CPT code(s).
All coverage criteria must be met before Medicare can reimburse this service.
When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)
GZ: Waiver of liability statement is not on file. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN.)
GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

See also Bill Type and Revenue Code sections below.

Part B Program Instructions:

Reasons for Denial

Cardiac Event Detection services using an answering service or answering machine as the receiving station is not covered.
Cardiac Event Detection that is not 24 hours a day, seven days a week attended is not separately payable. Such services have been described as the “King of Hearts,” “Event Monitor” and “Transtelephonic Arrhythmia Monitoring.” These services are not payable by Medicare.
Systems utilizing computers to dial the physician’s office so the physician receives transmission by way of a relay is not a covered service since there is no attendance.
Cardiac Event Detection is not covered for any patient who is unresponsive, comatose, severely confused or otherwise unable to recognize symptoms or activate the recorder.
Cardiac Event Detection is not covered for outpatient monitoring of recently discharged postinfarct patients.
“Routine” continued monitoring in the absence of treatable symptoms is considered screening and is not medically necessary.
All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD.
Service(s) rendered is not consistent with accepted standards of medical practice.
The medical record does not verify that the service described by the CPT/HCPCS code was provided.
The service does not follow the guidelines of the related LCD.
The service is considered:

Investigational.
For routine screening.
A program exclusion.
Otherwise not covered.
Never medically necessary.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.

Cardiac event monitoring must be 24 hours a day, seven days a week attended for reimbursement.
Cardiac Event Detection involves the long-term monitoring of patients to document a suspected or paroxysmal dysrhythmia. Therefore, it is considered medically unnecessary to utilize a Cardiac Event Detection service in place of a standard Electrocardiogram (ECG) or ECG rhythm strip. If it is necessary to transmit an ECG or ECG rhythm strip to another location for interpretation/report, then a standard ECG or ECG rhythm strip should be recorded and faxed to the interpreting physician. Only the ECG or ECG rhythm strip code may be billed.
All listed services are payable in an office (11) setting. Outpatient hospital settings and clinics (22) are additional payable places of service for physician review and interpretation (CPT code 93272). Home (12) and nursing facility settings (31, 32 and 33) are additional appropriate places of service for the hook-up of the monitor (CPT code 93270). Services to hospital inpatients are not reimbursable. Technical components of services to patients in a Part A SNF stay are not separately billable.
Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service.
To report these services, use the appropriate HCPCS or CPT code(s).
All coverage criteria must be met before Medicare can reimburse this service.
When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)
GZ: Waiver of liability statement is not on file. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN.)
GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit.

Bill Type and Revenue Codes below DO NOT apply to Part B.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.

073X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
93268©	Ecg record/review (Non-OPPS only)
93270©	Ecg recording (Non-OPPS only)
93271©	Ecg/monitoring and analysis
93272©	Ecg/review, interpret only

Other Comments

N/A