Cardiology Coding Alert

Calculate 5 Ways to Report 48-Hour ECG Evals

Plus: Get the date-of-service facts for 24-hour monitoring.

Assume billing 24-hour electrocardiogram (ECG) monitoring for 48-hour evaluations is a breeze? The answer may be more complicated than you think because the solution will depend upon your carrier's preference.

Many coders also express confusion about what day to report the Holter for 24-hour services. Does the date depend on when the cardiologist applied the device (initiated date) or when the cardiologist interpreted the results (completion date)? The answer is: It depends.

Here's a breakdown of the different approaches you might come across.

Research Global Vs. Component for 24-Hour Date

The descriptors for 93224-93227, 93230-93233, and 93235-93237 all begin with "Wearable electrocardiographic rhythm derived monitoring for 24 hours ..."

Reality: A 24-hour period translates to the hookup being performed on one day and the cardiologist performing the interpretation on another day. That means you have to determine which date of service your payer considers correct.

Generally, the Medicare rule is that you must bill services (or their components, if applicable) for the date of service on which the provider performs them.

For example, Cigna states "the technical component for recording as in 93225 or 93270 (Holter monitor and cardiac event recorder, respectively) would likely be one date whereas the date of the physician's interpretation (CPT codes 93227 or 93272) would be another" (

Global: If you are reporting the global service, however, such as 93224 (Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation), payers typically ask that you use the completion date (physician review date) as the date of service.

Cigna, for instance, states, "For global tests only, e.g.,Holter monitor that is billed with the global code only (for example, CPT code 93224), the date of service would be when the test was completed (i.e., interpreted) ... even though the code also includes hook-up which would have been done on another/earlier date of service."

Save time: Make sure you capture all charges for the patient on one fee slip. Physicians may forget "to circle the Holter CPT code, so oftentimes when I get the Holter slip in from the tech, the other charges have already been posted, and it gets really tedious doing the backtracking and cleanup work. Train everyone the way you want it done early," says Janet Gordon-Thatcher, senior bookkeeper of patient accounts at Summit Cardiology business office in Seattle.

Know 48-Hour-Service Option Essentials

The cardiologist may decide a certain patient requires monitoring for 48 hours or more, and you again will need to know the proper date of service. You also will need to know how many times to report the monitoring codes for the service.

The bottom line is that you will need to check each payer's preference, but below are the typical options you'll see.

Option 1: Report Each Date Separately

In some cases, cardiologists can report each test date separately.

For instance, you may be able to "bill 93227 (...physician review and interpretation) for each date of service -- as in, 93227 for Jan. 1 and 93227 for Jan. 2," says Kelly Wojciechowski, CCA, coding and compliance specialist at Wheaton Franciscan Healthcare in Milwaukee.

If the patient comes back in and the physician at least switches out the leads and battery, you may be able to report the global code (such as 93224) for each date.

Warning: Global code 93224 includes all the components of a Holter monitor: the connection (93225), the scanning analysis and report (93226), and physician review and interpretation (93227). Many practices have an outside company perform the scanning analysis and report (93226). If this is the case for your practice, you should stick to 93225 and 93227 as appropriate.

Typically, the policies that allow you to report 93227 twice instruct you to report the connection (93225) just once because the equipment isn't hooked up twice in 48 hour monitoring.

Option 2: Use Global Code Once

In other cases, insurers view long-term ECG monitoring as a complete service and do not allow you to report the global code (such as 93224) twice -- especially those adhering to frequency guidelines. Some of these guidelines dictate that a cardiologist can order a Holter monitor for a patient only once every six months.

Therefore, some insurers want the global code only one time.

Option 3: Append Modifier 22

Some practices report the global code with modifier 22 (Increased procedural service) or include two units of service to represent the 48-hour monitoring. Modifier 22 alerts insurers to the extra time and work on the monitoring procedure.

Option 4: Code Both Global, Pro Services Codes

Other coding professionals say that their payers require that they report the first date of service with the global code (such as 93224) because the cardiologist performed both the technical and professional services.

These insurers want physicians to report the second day's services with the professional component only (such as 93227).

The argument supporting these policies is that the cardiologist did not repeat the technical service, even though he may have.

You also may need to append modifier 76 (Repeat procedure by same physician), depending on payer preference.

Option 5: Rely on Modifier 59

Some insurers may require coders to append modifier 59 (Distinct procedural service) to separate component codes 93226 and 93227 from 93224.

Don't forget: Codes 93224-93227 aren't the only codes that describe Holter monitoring. These examples apply to other forms of Holter monitoring, as well: 93230-93233 and 93235-93237.

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