Pace Yourself For Optimal Coding Performance

Sustain a Healthy Rhythm for Cardiovascular Device Services

By G. John Verhovshek, MA, CPC

n February, you’re likely to turn your thoughts to matters of the heart. What a better time, then, to catch up on the latest changes in cardiac coding?

Evaluation and Management – CEMC

CPT® 2009 introduces significant revisions to cardiovascular medicine codes, including all-new codes for pacemakers, cardioverter-defibrillators, and other cardiovascular devices. To make way for these changes, the American Medical Association (AMA) eliminated codes 93727-93736 and 93741-93744, which previously reported many of these services.

Pacemakers

A cardiac pacemaker implanted in the chest delivers electrical impulses to pace the beats within a patient’s heart. The pacemaker may have one, two, or more leads delivering the electricity to regulate the heart’s movements. A pacemaker with pacing and sensing functions in a single chamber of the heart will have one lead, for instance, whereas a pacemaker with pacing and sensing functions in three chambers of the heart will have three leads.

To report the initial pacemaker evaluation and programming, both before and immediately after implantation, you will now call on 93286 Peri-procedural device evaluation and programming of device system parameters before or after a surgery, procedure, or test with physician analysis, review and report; single, dual, or multiple lead pacemaker system for reimbursement. CPT® guidelines clarify that you may report one unit of 93286 for a pre-procedure evaluation, and a second unit of 93286 for the first post-procedure evaluation. You should not report 93286 in addition to other pacemaker evaluation services, as described below.

Periodically, the physician must test a pacemaker, and possibly re-adjust it for optimal performance. Evaluations fall into four categories: transtelephonic rhythm strip evaluation, face-to-face interrogation device evaluation, remote interrogation device evaluation, and programming device evaluation.

Transtelephonic rhythm strip evaluations allow physicians to check a patient’s rhythm status remotely, and to verify the pacemaker is functioning well. Using a special transmitter, an impulse is sent via telephone and recorded at the physician’s site. New code 93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with physician analysis, review and report(s), up to 90 days describes the physician evaluation with analysis and report for evaluation of up to 90 days of stored data.

A similar remote service, 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), describes the physician’s work of downloading and evaluating up to 90 days of information stored within the pacemaker device, including programmed parameters, lead(s), battery status, capture and sensing function, and heart rhythm. A second code, 93296 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results, accompanies 93294 to report the technical portions of the service, including data acquisition and dissemination, receipt of transmissions, and technical review and support.

The physician also may provide an interrogation device evaluation face-to-face with the patient, as described by 93288 Interrogation 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.

A programming device evaluation includes all interrogation device evaluation components as described by 93288 or 93294, and further includes the selection of patient-specific programmed parameters. The appropriate CPT® code to describe this service depends on the number of leads in the pacemaker system:

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

93280          dual lead pacemaker system

93281          multiple lead pacemaker system

The AMA’s CPT® 2009 Professional Edition (p. 410) lists the components that may be included in a programming device evaluation as described by 93279-93281.

Cardioverter Defibrillators

An implantable cardioverter defibrillator is therapeutic for patients with recurrent and sustained ventricular tachycardia or fibrillation. These devices can work like pacemakers, or can intervene when the cardiac rhythm is irregular, delivering stronger shocks as needed. They may have one, two, or multiple leads, depending on the patient’s clinical condition.

Like a pacemaker, a cardioverter-defibrillator requires initial and subsequent programming, as well as periodic evaluation. For an evaluation and programming either before and/or immediately after surgery, a procedure, or test, select 93287 Peri-procedural device evaluation and programming of device system parameters before or after a surgery, procedure, or test with physician analysis, review and report; single, dual, or multiple lead implantable cardioverter-defibrillator system.

For a cardioverter-defibrillator’s in-person interrogation device evaluation , select 93289 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead implantable cardioverter-defibrillator system, including analysis of heart rhythm derived data elements.

For a remote interrogation device evaluation, report 93295 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable cardioverter-defibrillator system with interim physician analysis, review(s) and report(s) for the physician portion of the service, with 93296 to describe receipt of transmissions, technical review and support, and data dissemination.

A cardioverter-defibrillator interrogation device evaluation, whether in-person or remote, requires examination of programmed parameters, lead(s), battery, capture and sensing function, presence or absence of therapy for ventricular tachyarrhythmias and underlying heart rhythm.

You should select a code for more-extensive programming device evaluation, which can also include sensor rate response, lower and upper heart rates, and atrioventricular (AV) intervals, among other components, according to the number of leads in the cardioverter-defibrillator system.

93282      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 implantable cardioverter-defibrillator system

93283         dual lead implantable cardioverter-defibrillator system

93284         multiple lead implantable cardioverter-defibrillator system

Implantable loop devices

Implantable loop devices (ILDs) are useful in diagnosing the cause of syncope recurrent palpitations, or seizures in patients. Syncope can be caused by life-threatening arrhythmias. Devices such as Medtronic’s Reveal® Plus are designed to record electrocardiograms (EKGs) as cardiac events are experienced by the patient. This helps physicians establish a definitive diagnosis. These devices require periodic evaluation and testing, which can include remote or in-person services.

For face-to-face interrogation device evaluation, including programmed parameters, and the heart rate and rhythm during recorded episodes, you should select 93291 Interrogation device evaluation(s), (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable loop recorder system, including heart rhythm derived data analysis).

To report remote interrogation device evaluation, claim 93298 Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, physician analysis, review(s) and report(s) for the physician portion on the service. Code 93299 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remove data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results describes the technical portion of the service, including transmission receipt and technician review. You should not report a remote service more than once per 30 days.

If the physician instead provides programming device evaluation of an implantable loop recorder system, which includes all the components of interrogation device evaluation, plus possible adjustment of tachycardia and bradycardia detection criteria, you should claim 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; implantable loop recorder system.

Wearable Defibrillators

A wearable defibrillator, for example the LifeVest® from ZOLL LifeCor, is worn outside the body rather than  being implanted. It includes an electrode belt and a monitor. It records and treats arrhythmic conditions in the patient and provides continuous EKG monitoring.

Physicians evaluate a wearable defibrillator in person, by interrogation device, as reported with 93292 Interrogation device evaluation [in person] with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; wearable defibrillator system). Note that you should report the initial setup for a wearable defibrillator using 93745 Initial set-up and programming by a physician of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events. Do not report 93292 and 93745 simultaneously.

Cardiovascular Monitoring Systems

Although implanted, a cardiovascular monitor system does not have pacing or defibrillator functions. Rather, it detects and records heart data only. You should report 99290 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors when a physician meets with a patient face-to-face to download and evaluate the information stored within an implantable cardiovascular monitor system device, including battery status and all recordings of heart activities.

For remote physician interrogation of a cardiovascular monitor system, look to 93297 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, physician analysis, review(s) and report(s). You may report the technical portion of this service (transmission receipt, technician review, etc.) separately, when provided, using 93299. CPT® guidelines prohibit you from reporting a remote interrogation for an implantable cardiovascular monitor system more frequently than once every 30 days.

Ambulatory Event Monitors

Like a Holter monitor, ambulatory event monitors (AEMs) are noninvasive devices used to diagnose or identify heart arrhythmias by recording heart activity for later evaluation. AEMs record a “loop” of heart action, erasing past recordings so that the record is limited. They can also be trigged by events—for example, only recording when the heart rate exceeds a certain threshold or when the patient pushes a button.

CPT® 2009 introduces two new codes to describe AEM-related services:

93228      Wearable 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; physician review and interpretation with report

93229          technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports

These codes report AEM with real-time data analysis and transmission, called mobile outpatient cardiac telemetry. Examples of these devices are the CardioNet and the HEARTlink II™ monitoring devices. Code 93228 describes the physician’s interpretation and review of the AEM report, while 93229 includes the technical support required for the AEM report’s creation and transmission.

Descriptors for AEM codes 93224-93227 and 93230-93727 include modified language to accommodate new codes 93228 and 93229, and to clarify use for the existing codes.

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