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Cardiology Coding Alert

The Spotlight's on Holter Monitors - Can You Withstand Scrutiny?

Published on Sun Sep 19, 2004

 4 expert tips help you realize long-term EKG reimbursement

To code 24- or 48-hour Holter monitors accurately, you should know whether the devices are patient-activated or are nonpatient-activated continuous recorders.
 
Now that CMS has unveiled a new framework for ambulatory electrocardiography (AECG) or Holter monitor codes, it's even more important that you get your codes right. These four pointers will help.

Tip 1: Take Note of CMS' Memo on Carrier Decision-Making

Ambulatory echocardiographic monitoring cost Medicare $22.7 million in 2001, so it's no wonder that CMS wants to keep tabs on these services. 
 
AECG or Holter monitors record patients during their daily activities (including sleep) and document symptoms of cardiac arrhythmias. An Aug. 26 coverage memo from CMS laid down a framework for carriers to decide whether and how to cover these devices, which patients often wear for up to 24 hours in an outpatient setting.
 
CMS didn't decide which devices to cover or give the carriers specific instructions. Instead, the agency provides carriers with a framework to divide the devices into categories.
 
CMS spells it out: CMS' framework divides devices into patient-activated recorders and nonpatient-activated continuous recorders such as the Holter. Patient-activated recorders are divided depending on whether they have a "presymptom memory loop" and whether there's a technician and physician on call to look at the results in real time.
 
"I've noticed that larger insurance companies have adopted the federal regulations on most of these procedures," says Angelina Hamilton, LPN, CPC, lead coder for Lake Regional Medical Management in Osage Beach, Mo. So knowing a little more about how they determine coverage can help you in the long run.

Tip 2: Know Your Long-Term EKG Technology
 
When reporting Holter monitor testing, your first dilemma is choosing the correct CPT code series to use. You'll find that 93224-93227, 93230-93233, and 93235-93237 each describe a slightly different Holter monitor technique.
 
You will need to know what technology you have, because these codes vary from each other according to heart rhythm recording, storage, and analysis:

Nonpatient-Activated Continuous Recorders:

  • 93224 - Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation
  • 93230 - Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation.

    Patient-Activated Event Markers:

  • 93235 - Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and noncontinuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient-activated; includes monitoring and real-time data analysis with report, physician review and interpretation.

    The new CMS framework suggests that carriers should make reimbursement decisions based on the categories of nonpatient-activated continuous recorders and patient-activated event markers, so make sure you know which code is right for your practice's technology.
     
    Not sure how to find out? "Meet with the techs to determine the kinds of monitoring devices you are working with," says Sarah Tupper, CMC, coding specialist for Central New York Cardiology in Utica, N.Y.

    Tip 3: Avoid Coding Inappropriate Components

    Be aware: You should report the codes listed above only if the physician performs all of the subscribed services. They represent the global service. But if the cardiologist performs only one of these tasks, you should code that individual service.
     
    Suppose your cardiologist reviews and interprets the data but another facility owns the equipment. "We send our patients to the local hospital for the hookup, recording, and disconnection of the Holter monitors," Hamilton says. If this is also the case in your practice, you should report 93227 (Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; physician review and interpretation).
     
    Warning: You should not append modifier -26 (Professional component) to 93224. CPT divides the Holter monitoring service into three components: the actual use of the device (93224), the supervision and interpretation of the results (93227), and additional aspects of the procedure, such as hooking up and disconnecting the recording device. You should code those aspects with 93225 (... recording [includes hookup, recording, and disconnection]) and 93226 (... scanning analysis with report).
     
    Best strategy: The easiest way to be sure whether or not modifier -26 applies is to look up the code in the Medicare fee schedule and see if the code is listed three times: once with no modifiers indicating the full service, once with -26, and once with -TC (Technical component).

     Note: You can find the Medicare fee schedule at      http://www.cms.hhs.gov/physicians/mpfsapp/.

    Tip 4: Check With Insurers for Correct Date of Service

    Many coders express confusion about what day to report the Holter. Does the date depend on when the cardiologist applied the device (initiated date) or when the cardiologist interpreted the results (completion date)? Unfortunately, the answer is - it depends.
     
    "We bill the day the Holter was applied," Tupper says. You can usually report the Holter code this way, like other diagnostic test interpretations, but "usually" does not mean "always."
     
    For instance: If the patient goes to a hospital for the Holter monitor connection, you may report one aspect of the code series (93224-93227) - such as the physician review and interpretation (93227) - on the date the hospital disconnects and downloads the monitor, Hamilton says.
     
    "Do your research ahead of time," Tupper says.

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