L28832-LCD

Automated World Health

Local Coverage Determination (LCD) for External Electrocardiographic Recording] (L28832)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28832

LCD Title External Electrocardiographic Recording]

Primary Geographic Jurisdiction opens in new window Florida

Contractor's Determination Number A93224

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date ANTICIPATED 10/08/2012

Revision Effective Date

For services performed on or after 10/01/2011 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub 100-03, Medicare National Coverage, Chapter 1, Section 20.15

Indications and Limitations of Coverage and/or Medical Necessity

Electrocardiographic monitoring can be performed on ambulatory patients over a set period of time (usually twenty four hours). The monitoring device (holter monitor) allows the patient to resume their normal lifestyle and activities while recording episodes of arrhythmia. This gives the physician documented episodes of arrhythmias or absence of arrhythmias to correlate with the patient's symptoms.

Medicare will consider twenty-four hour electrocardiographic monitoring to be medically necessary in any of the following circumstances (see Covered ICD-9 Codes):

The patient complains of palpitations, and physical examination and standard EKG have not satisfactorily explained the patient's complaints.

The patient has experienced an unexplained syncopal episode or the patient has experienced a transient episode of cerebral ischemia which is felt to possibly be secondary to a cardiac rhythm disturbance.

The patient has been found to have a significant cardiac arrhythmia or conduction disorder (see list below) and holter monitoring is necessary as part of the evaluation and management of the patient:

Complete Heart Block Second Degree AV Block

New Left Bundle Branch Block New Right Bundle Branch Block Bifasicular Block

Paroxysmal SVT Paroxysmal VT Atrial Fib/Flutter

Ventricular Fib/Flutter Cardiac Arrest

SA Node Dysfunction Frequent PAC's Frequent PVC's

Wandering Atrial Pacemaker Unspecified Cardiac Arrhythmia

The patient has a heart condition (see list below) associated with a high incidence of serious cardiac arrhythmia and/or myocardial ischemia, and holter monitoring is being done as part of the evaluation and management of the patient:

Dressler's Syndrome

History of Myocardial Infarction Angina Pectoris

Prinzmetals's Angina Aneurysm of Heart Wall

Chronic Ischemic Heart Disease Pericarditis

Mitral Valve Disease

Cardiomyopathy Anomalus AV Excitation Cardiomegaly

Post Heart Surgery Prolonged QT Interval

The patient has a cardiac arrhythmia or other cardiac condition and a cardiac medication which affects the electrical conduction system of the heart has been prescribed, and holter monitoring is necessary to evaluate the effect of the cardiac medication on the patient's cardiac rhythm and/or conduction system.

The patient has a pacemaker and clinical findings (history or physical examination) suggest possible pacemaker malfunction.

Claims submitted for holter studies performed at unusually frequent intervals will be reviewed by Medicare to make certain that the services were medically reasonable and necessary.

Coding Information

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.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital

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.

0730 EKG/ECG (Electrocardiogram) - General Classification 0731 EKG/ECG (Electrocardiogram) - Holter Monitor

CPT/HCPCS Codes

EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM

93224 RECORDING AND STORAGE; INCLUDES RECORDING, SCANNING ANALYSIS WITH REPORT, PHYSICIAN REVIEW AND INTERPRETATION

93225 EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)

93226 EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; SCANNING ANALYSIS WITH REPORT

93227 EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; PHYSICIAN REVIEW AND INTERPRETATION

ICD-9 Codes that Support Medical Necessity

410.00 - 410.92 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

411.0 - 411.89 POSTMYOCARDIAL INFARCTION SYNDROME - OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER

412 OLD MYOCARDIAL INFARCTION

413.0 - 413.9 ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

414.1 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT

414.2 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY

414.3 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT

414.4 CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT

414.6 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART

414.7 CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART

414.10 ANEURYSM OF HEART (WALL)

414.11 ANEURYSM OF CORONARY VESSELS

414.19 OTHER ANEURYSM OF HEART

414.4 CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION

414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE

414.9 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED

423.1 ADHESIVE PERICARDITIS

423.2 CONSTRICTIVE PERICARDITIS

424.0 MITRAL VALVE DISORDERS

425.0 - 425.9 ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED

426.0 ATRIOVENTRICULAR BLOCK COMPLETE

426.12 MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK

426.13 OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK

426.2 LEFT BUNDLE BRANCH HEMIBLOCK

426.4 RIGHT BUNDLE BRANCH BLOCK

426.53 OTHER BILATERAL BUNDLE BRANCH BLOCK

426.7 ANOMALOUS ATRIOVENTRICULAR EXCITATION

426.82 LONG QT SYNDROME

426.9 CONDUCTION DISORDER UNSPECIFIED

427.1 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

427.2 PAROXYSMAL VENTRICULAR TACHYCARDIA

427.31 - 427.32 ATRIAL FIBRILLATION - ATRIAL FLUTTER

427.41 - 427.42 VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER

427.5 CARDIAC ARREST

427.61 SUPRAVENTRICULAR PREMATURE BEATS

427.69 OTHER PREMATURE BEATS

427.81 - 427.89 SINOATRIAL NODE DYSFUNCTION - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS

427.9 CARDIAC DYSRHYTHMIA UNSPECIFIED

429.3 CARDIOMEGALY

429.4 FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY

429.9 HEART DISEASE UNSPECIFIED

780.2 SYNCOPE AND COLLAPSE

785.1 PALPITATIONS

E942.0* CARDIAC RHYTHM REGULATORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E942.1* CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V45.00* UNSPECIFIED CARDIAC DEVICE IN SITU

V45.01* CARDIAC PACEMAKER IN SITU

V45.02* AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR IN SITU V45.09* OTHER SPECIFIED CARDIAC DEVICE IN SITU

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

* According to the ICD-9-CM book, diagnosis codes E942.0, E942.1, V45.00, V45.01, V45.02, V45.09 are secondary diagnosis codes and should not be billed as the primary diagnosis.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the ordering/referring physician must clearly indicate the medical necessity of holter monitor studies covered by the Medicare program. Also, the results of holter studies covered by the Medicare program must be included in the patient's medical record.

If the provider of holter studies is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation along with copies of the ordering/referring physician's order for the study. When ordering holter studies from an independent physiological lab or other

provider, the ordering/referring physician must state the reason for the holter study in his order for the test.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Abbott, A. (2005). Diagnostic Approach to Palpitations. American Family Physician 71(4).

Arend, W., Armitage, J., Drazen, J., Eds, et al (2004). Goldman: Cecil Textbook of Medicine, 22nd ed. W.B. Saunders Company.

Sivaskumaran, S., Krahn, A., et al (2003). A prospective randomized comparison of loop recorders versus Holter monitors in patients with syncope or presyncope. American Journal of Medicine 115 (1).

Zipes, D., Libby, P., et al (2005). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. Elsevier.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation

with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/2011

Revision History Number 2

Revision History Explanation Revision Number: 2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Added diagnosis code 414.4. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2011 Revision Effective Date 01/01/2011

LCR A2011-009

December 2010 Bulletin

Explanation of Revision: Annual 2011 HCPCS Update. Descriptor revised for CPT codes 93224, 93225, 93226, and 93227. Deleted CPT codes 93230, 93231, 93232, 93233, 93235, 93236, and 93237. LCD title changed to ‘External Electrocardiographic Recording’. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28832) replaces LCD L1127 as the policy in notice. This document (L28832) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0730 was changed 8/1/2010 - The description for Revenue code 0731 was changed

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

93224 descriptor was changed in Group 1 93225 descriptor was changed in Group 1 93226 descriptor was changed in Group 1 93227 descriptor was changed in Group 1

11/21/2010 - The following CPT/HCPCS codes were deleted: 93230 was deleted from Group 1

93231 was deleted from Group 1

93232 was deleted from Group 1

93233 was deleted from Group 1

93235 was deleted from Group 1

93236 was deleted from Group 1

93237 was deleted from Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change