Cardiology Coding Alert

Knowing the difference between in-person and remote evaluations will make your coding choice easier, as well.

When your cardiologist performs evaluations remotely, flipping between the applicable codes (93293 and 93294-93296) and the CPT section guidelines can be tedious and time-consuming. We've done the work for you, pairing these codes with the guidelines that go with them.

Start here: There are a couple of key concepts that apply to all the codes in this range:

Remote: CPT guidelines specify this means data is obtained remotely, which distinguishes these codes from in-person interrogation codes 93288-93292 (Interrogation device evaluation [in person] with physician analysis, review and report, includes connection, recording and disconnection per patient encounter ...). The remote codes include retrieving and evaluating stored and measured information to determine the device's current programming. The exact components evaluated depend on the specific device, as discussed in the sections below.

Once every 90 days: CPT guidelines tell you to report these remote evaluation codes no more than once every 90 days. Do not report these codes if the monitoring period is less than 30 days. This rule is different than the in-person codes, which are reported per procedure.

Tackle 93293 Transtelephonic Requirements

CPT guidelines for 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) say you should use it for "service for 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 strip is recorded both with and without a magnet placed over the pacemaker. It is evaluated for both heart rate and rhythm, "atrial and ventricular capture (if observed) and atrial and ventricular sensing (if observed)," guidelines state.

The battery status is also evaluated by measurement of the paced rate on the strip recorded with the magnet applied.

Example: CPT Changes 2009: An Insider's View offers a clinical example in which a 69-year-old patient with complete heart block has a six-year-old dual-chamber pacemaker that is being monitored for battery depletion with transtelephonic rhythm strip pacemaker evaluations. A transtelephonic monitoring (TTM) rhythm strip is recorded for 30 seconds and evaluated for heart rate and capture, sensing of each lead, and for atrial or ventricular arrhythmias.

A second rhythm strip is recorded after the patient places a magnet over the implanted generator. When the magnet is in place, the generator will pace the patient's heart at a rate which directly correlates with the amount of battery that remains in the device. Therefore, analysis of the magnet rate will provide an indicator of how much longer the patient can go before requiring a new generator. If the battery longevity drops unexpectedly fast it would trigger a more extensive, inperson evaluation of the implanted system, says Jim Collins, CCC, CPC, CHCC, president of CardiologyCoder.com Inc. in Saratoga Springs, N.Y.

Use 93294-93296 For Remote Evaluations

According to CPT guidelines, "Interrogation device evaluation (remote) is a procedure performed for patients with pacemakers, implantable cardioverter-defibrillators, or implantable loop recorders using data obtained remotely."

You'll use codes 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]) and 93295 (... implantable cardioverter-defibrillator system with interim physician analysis, review[s] and report[s]) to report the professional portion of the remote monitoring. Use 93294 for evaluating pacemakers and 93295 to evaluate ICDs.

Report 93296 (... remote data acquisition[s], receipt of transmissions and technician review, technical support and distribution of results) for the technical portion of the service. You should use 93296 for the technical portions of both pacemaker and defibrillator remote monitoring.

In general, the professional portion of the service is everything that the physician does: supervision, interpretation, and report. The technical component is the work of the technician who obtains the data and also the overhead expenses needed to perform the service: electricity, computer, Internet connection, etc., Collins says.

Remote Doesn't Require System Differentiation

There are three types of pacemakers: single lead, dual lead, and multiple lead. A single-lead pacemaker performs pacing and sensing function in only one chamber of the heart. A duallead pacemaker performs pacing and sensing function in two chambers, and multiple-lead performs pacing and sensing function in three or four chambers. "At the time of publication there are no FDA approved "four chamber" devices so multiple lead systems are limited to biventricular devices that facilitate pacing/sensing in the right atrium, right ventricle, and left ventricle," Collins cautions.

When billing for remote monitoring and TTMs, it is not necessary to differentiate between single, dual, or multiple chamber systems. However, in-person programming evaluation (93279-93285) requires you to properly identify and report the type of device being evaluated, Collins says.

An ICD is "an implantable device that provides high-energy and low-energy stimulation to one or more chambers of the heart to terminate rapid heart rhythms called tachycardia or fibrillation," says CPT. Like pacemakers, CPT refers to ICDs as single, dual, and multiple lead devices.

The guidelines also indicate that 2010 remote interrogation codes 93294-93296 require evaluation of the following:

• Programmed parameters
• Lead(s)
• Battery
• Capture and sensing function
• Presence or absence of therapy for ventricular tachyarrhythmias (for ICDs)
• Underlying heart rhythm.

Pay Attention to Reporting Guidelines

You should report remote interrogation codes 93293-93296 only once every 90 days. "A period is established by the initiation of the remote monitoring or the 91st day of a pacemaker or implantable cardioverter-defibrillator (ICD) monitoring ... and extends for the subsequent 90 [days] for which remote monitoring is occurring," according to CPT guidelines.

According to Collins, "CMS has indicated that the appropriate date of service for each monitoring period is the date that the 90-day monitoring is completed." He adds, "It is occasionally necessary to interrogate devices more frequently than once every 90 days.

Since it is appropriate to report the end of the 90-day period as the date of service, it is not necessary to keep track of the interrogation dates in the billing system. The remote monitoring Web sites can keep track of them for us and eliminate the need to reconcile every patient's account every time we do an interrogation."

Pointer: "I actually use a website (timeanddate.com) to plug in the last transmission date and the current one, and it calculates the days in between for me," says Maryann Fanning, CPC, physician services coder at Holy Redeemer Health System in Meadowbrook, Penn. "If a patient transmits more than once within that timeframe, we enter the charge to capture the work, but do not bill it out," she adds.

Support Your Evaluation Coding With a Sound ICD-9 Code

Check your policies to see which codes support medical necessity.

For some policies, codes that may support remote evaluations include multiple codes in the 426.xx (Conduction disorders) range, 785.1 (Palpitations), and V45.XX and V53.XX series. These may be the same as the codes used for an in-person evaluation.