L32820 LONG-TERM WEARABLE ELECTROCARDIOGRAPHIC MONITORING (WEM)

 

01/01/2013

 

Indications and Limitations of Coverage and/or Medical Necessity

 

WEM are generally classified by the following:

1. Non-Activated Continuous Recorders (holter monitor/external electrocardiographic recording) (CPT codes 93224 – 93227) provide a continuous record of heart rhythm over a set period of time (usually twenty four hours) and up to a 48 hour period.

• This procedure can often identify the existence of ECG rhythm derived elements that are missed on a standard ECG.

• This service is appropriate when arrhythmias are known or suspected to occur at least once in 48 hours 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.

• This local coverage determination policy is being developed to clearly define the circumstances for which twenty-four hour continuous electrocardiographic monitoring is considered to be medically reasonable and necessary, and therefore covered.

• Twenty-four hour electrocardiographic monitoring is medically necessary in any of the following circumstances (see Covered ICD-9-CM codes):

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

o 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:

o Complete Heart Block.

o Second Degree AV Block.

o New Left Bundle Branch Block.

o New Right Bundle Branch Block.

o Bifascicular Block.

o Paroxysmal SVT.

o Paroxysmal VT.

o Atrial Fib/Flutter.

o Ventricular Fib/Flutter.

o Cardiac Arrest.

o SA Node Dysfunction.

o Frequent PAC's.

o  Frequent PVC's.

o Wandering Atrial Pacemaker.

o 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:

o Dressler's Syndrome.

o History of Myocardial Infarction.

o Angina Pectoris.

o Prinzmetals's Angina.

o Aneurysm of Heart Wall.

o Chronic Ischemic Heart Disease.

o Pericarditis.

o Mitral Valve Disease.

o Cardiomyopathy.

o Anomalous AV Excitation.

o Cardiomegaly.

o Post Heart Surgery.

o 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 to make certain that the services were medically reasonable and necessary.

 

2. Patient/Event-Activated Intermittent Recorders (loop event monitors, remote cardiovascular monitoring) (CPT codes 93228, 93229, and 93268 - 93272) are indicated when:

o Symptoms are sporadic to establish whether or not they are caused by transient arrhythmias.

o This service is an appropriate alternative to 48 hour monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope or syncope) or when a 48 hour service is not diagnostic.

• Ambulatory electrocardiography (AECG) refers to services rendered in an outpatient setting over a specified period of time, generally while a patient is engaged in daily activities, including sleep.

o AECG devices are intended to provide the physician with documented episodes of arrhythmia, which may not be detected using a standard 12-lead EKG.

o AECG is most typically used to evaluate symptoms that may correlate with intermittent cardiac arrhythmias and/or myocardial ischemia.

o Such symptoms include syncope, dizziness, chest pain, palpitations, or shortness of breath.

o Additionally, AECG is used to evaluate patient response to initiation, revision, or discontinuation of arrhythmic drug therapy.

• An event recorder is a portable unit, attached to a patient, which permits the patient to record an EKG rhythm strip at the onset of symptoms (e.g., syncope, dizziness) or in response to a physician’s order (e.g., immediately following strong physical exertion).

o Most devices also permit the patient to simultaneously voice-record in order to describe the symptoms and/or activity concurrently.

o There are two basic types of event recorders (post-event and pre-event), which are differentiated on the basis of memory.

• When the goal is to correlate the patient’s rhythm or EKG pattern with symptoms that are very infrequent (at weekly intervals or more), the patient activated event recorder is the optimal choice.

o However, if the patient’s symptoms are of such brief duration (seconds) or severity (frank syncope) to preclude capture by such a unit, then a loop event recorder is required.

o It is important to correlate an abnormal rate and rhythm with cardiovascular symptomatology and determine the precise mechanism of the arrhythmia.

Medicare will consider the use of patient demand single or multiple event recorders medically reasonable and necessary under the following circumstances:

• When indicated for the detection, characterization, and documentation of symptomatic transient arrhythmias, when the frequency of the symptoms is limited and use of a 24-hour ambulatory EKG is unlikely to capture and document the arrhythmia.

• A definitive diagnosis has not been made after all of the following conditions have been met:

o The patient has undergone a complete history and physical by a physician prior to the initiation of monitoring.

 The history and physical must indicate that the patient is experiencing recurrent, transient symptoms suggestive of cardiac arrhythmia (Note: Palpitations are extremely common in healthy individuals.)

 Therefore, if ICD-9 code 785.1 (Palpitations) is billed as the diagnosis supporting medical necessity, the history and physical or other pertinent medical record documentation must support the presence of associated symptoms such as dizziness, shortness of breath, chest discomfort, or an underlying history of cardiac disease.

And

o The patient has undergone a 12 lead EKG and rhythm strip.

o A physician overseeing the medical management of the patient orders the medically necessary patient demand event recorder.

o Any device used for event recording must be FDA approved for the indication for which it is being utilized.

o The FDA approved device must be capable of transmitting EKG leads I, II, or III (the standard limb leads).

 To generate a sufficient EKG rhythm strip, the device must either have “built in” electrodes, such that placement of the device on the patient’s precordium produces an EKG reading of lead I, II, or III, or the device involves the proper placement/attachment of at least two electrodes to the patient.

 Because it is not practical to attach electrodes to the arms and legs, modifications of the standard limb leads must be utilized.

 Electrode placement for the monitor limb leads is similar to standard placement, except that the left and right shoulder or subclavian areas and the lower left quadrant of the abdomen are used for electrode placement.

 The following are the sites for proper lead placement to generate a lead I, II, or III:

 LEAD / + ELECTRODE / - ELECTRODE:

• I / Lt. subclavian (shoulder) / Rt. subclavian (shoulder)

• II / Lt. lower quadrant abdomen / Rt. subclavian (shoulder)

 III / Lt. lower quadrant abdomen / Lt. subclavian (shoulder)

 The transmission of the EKG lead I, II, or III must be sufficiently comparable to readings obtained by conventional EKG to permit proper interpretation of abnormal cardiac rhythms.

 EKG tracings normally consist of three identifiable waveforms: the P wave (depicting atrial depolarization), the QRS complex (depicting ventricular depolarization), and the T wave (depicting ventricular repolarization).

 The lead II rhythm strip depicts the heart’s rhythm more clearly than any other waveform.

• A provider of the service must be capable of receiving and recording transmissions 24-hours per day, every day of the year.

o This is applicable to those CPT codes whose descriptor indicates “24-hour attended monitoring”

o This includes receipt of the EKG signal, as well as the voice transmission relating any associated symptoms.

• The designated monitoring facility must have on-site 24-hour availability of an attendant trained in equipment operation and on-line analysis of the transmitted EKG tracing when CPT codes requiring 24-hour attended monitoring are ordered.

• The transmissions must be received by a person capable of responding to the transmission.

o The transmission is not to be received by an answering machine for review at a later time when CPT codes requiring 24-hour attended monitoring are ordered.

• The person receiving the transmission must be a technician, nurse, or physician trained in interpreting EKGs and abnormal rhythms.

o A physician must be available for immediate consultation to review the transmission, in case of significant symptoms or EKG abnormalities, when CPT codes requiring 24-hour attended monitoring are ordered.

o A provider of the service must be capable of immediately notifying the patient’s attending physician when indicated.

o The referring physician’s telephone number and other emergency instructions for the patient should be included in the referral for the monitoring services.

o The recording device and transmission equipment must be verifiably in the patient’s possession for the entire thirty day period of submission.

• The patient must be instructed in and capable of facile operation of both the recording device and the transmission device.

o Therefore, the patient must not be limited by a medical condition that would indicate that the patient is incapable of the proper operation of the device (e.g., a patient with senile dementia, Organic Brain Syndrome (OBS), Alzheimers, mental retardation, etc.).

o If a responsible party is required to assist the patient in the device operation and transmissions, that party must be present on a 24-hour basis.

o The instructions regarding the operation of the device, changing the batteries, etc. must be given by the provider of the monitoring service to the patient/responsible party prior to initiation of use of the patient demand event recorder.

• The use of, external electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage (CPT codes 0295T, 0296T, 0297T and 0298T) has not been demonstrated to be a standard of care.

o This contractor will address under individual consideration the medical necessity for these services.

 

 

CPT/HCPCS Codes

 

*Category III codes require documentation for review and individual consideration.

 

*0295T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review, and interpretation

 

*0296T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording)

 

*0297T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report

 

*0298T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation

93224 EXTERNAL ELECTROCARDIOGRAPHIC RECORDING UP TO 48 HOURS BY CONTINUOUS RHYTHM RECORDING AND STORAGE; INCLUDES RECORDING, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

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; REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

93228 EXTERNAL 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; REVIEW AND INTERPRETATION WITH REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

93229 EXTERNAL 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; TECHNICAL SUPPORT FOR CONNECTION AND PATIENT INSTRUCTIONS FOR USE, ATTENDED SURVEILLANCE, ANALYSIS AND TRANSMISSION OF DAILY AND EMERGENT DATA REPORTS AS PRESCRIBED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

93268 EXTERNAL PATIENT AND, WHEN PERFORMED, AUTO ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDING WITH SYMPTOM-RELATED MEMORY LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 DAYS, 24-HOUR ATTENDED MONITORING; INCLUDES TRANSMISSION, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

93270 EXTERNAL PATIENT AND, WHEN PERFORMED, AUTO ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDING WITH SYMPTOM-RELATED MEMORY LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 DAYS, 24-HOUR ATTENDED MONITORING; RECORDING (INCLUDES CONNECTION, RECORDING, AND DISCONNECTION)

93271 EXTERNAL PATIENT AND, WHEN PERFORMED, AUTO ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDING WITH SYMPTOM-RELATED MEMORY LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 DAYS, 24-HOUR ATTENDED MONITORING; TRANSMISSION AND ANALYSIS

93272 EXTERNAL PATIENT AND, WHEN PERFORMED, AUTO ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDING WITH SYMPTOM-RELATED MEMORY LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 DAYS, 24-HOUR ATTENDED MONITORING; REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

 

 

ICD-9 Codes that Support Medical Necessity

 

ICD-9 Codes that Support Medical Necessity For CPT codes 93224-93229

 

410.00-410.92 Acute myocardial infarction

411.0-411.89 other acute and subacute forms of ischemic heart disease

412 Old myocardial infarction

413.0-413.9 Angina pectoris

414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft

414.01 Coronary atherosclerosis of native coronary artery

414.02 Coronary atherosclerosis of autologous biological bypass graft

414.03 Coronary atherosclerosis of nonautologous biological bypass graft

414.06 Coronary atherosclerosis of native coronary artery of transplanted heart

414.07 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 Cardiomyopathy

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

427.0 Paroxysmal supraventricular tachycardia

427.1 Paroxysmal ventricular tachycardia

427.31-427.32 Atrial fibrillation and flutter

427.41-427.42 Ventricular fibrillation and flutter

427.5 Cardiac arrest

427.61 Supraventricular premature beats

427.69 Other premature beats

427.81-427.89 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* Agents primarily affecting the cardiovascular system, cardiac rhythm regulators

E942.1* Agents primarily affecting the cardiovascular system, cardiotonic glycosides and drugs of similar action

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 and V45.09 are secondary diagnosis codes and should not be billed as the primary diagnosis

 

 

ICD-9 Codes that Support Medical Necessity for 93268-93272

 

427.81 - 427.89 Sinoatrial node dysfunction - other specified cardiac dysrhythmias

427.9 Cardiac dysrhythmia unspecified

780.2 Syncope and collapse

780.4 Dizziness and giddiness

785.1 Palpitations

786.09 Respiratory abnormality other

786.50 - 786.59 Unspecified chest pain - other chest pain

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

 

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

 

 

Documentation Requirements

 

• Medical record documentation maintained by the ordering/referring physician must clearly indicate the medical necessity of holter monitor studies covered.

o Also, the results of holter studies 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.

o 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.

• Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner (e.g., complete history and physical, 12 lead EKG, and rhythm strip performed prior to initiation of the patient demand event recorder) must indicate the medical necessity for use of the patient demand single or multiple event recorder.

o If ICD-9-CM code 785.1 (Palpitations) is the diagnosis billed, the history and physical or other pertinent medical record documentation must support the presence of associated symptoms such as dizziness, shortness of breath, chest discomfort, or an underlying history of cardiac disease.

o The medical record should support that specific symptoms (syncope, dizziness, chest pain, palpitations, or shortness of breath) may correlate with intermittent cardiac arrhythmias and/or myocardial ischemia.

• If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, the order must state.

o The indication/medical necessity for the patient demand event recorder.

And

o The provider of the service is responsible for ensuring that all of the necessary coverage criteria have been met prior to the initiation of the patient demand event recorder.

• The EKG rhythm strip transmission and interpretation must include the following information:

o The name of the patient, the presenting diagnosis.

o The time and date of the transmission.

o The lead of the EKG transmission, the PR interval.

o The QRS interval.

o The rate.

o The rhythm.

o The signature of the person interpreting the EKG strip.

o Cardiovascular symptomatology reported by the patient at the time of the transmission.

o Any necessary actions (e.g., notification of physician, emergency instructions given to patient. etc.) taken by the person interpreting the EKG rhythm strip.

• Claims for external electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage (CPT codes 0295T, 0296T, 0297T and 0298T) will be addressed under individual consideration.

o Medical records may be requested for prepayment review.

o The documentation must clearly support for each individual patient, the medical necessity for the use of external Electrocardiographic recording for more than 48 hours up to 21 days.

o The record should clearly outline the indication (diagnostic criteria) and its medical need.

 

 

Utilization Guidelines

 

• No more than one 48 hour WEM service would be expected in a 6 month period.

• No more than one 30 day WEM service would be expected in a 6 month period.

• Use of WEM more frequently than at 6 month intervals requires physician documentation in the progress notes specifically supporting the medical necessity of a more frequent interval.

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

 

 

Treatment Logic

• Long-term wearable electrocardiographic monitoring (WEM) is a diagnostic procedure that provides a record of the heart rhythm during daily activities.

• This procedure can often identify the existence and determine the frequency of clinically significant rhythm disturbances and waveform abnormalities that are missed on a standard electrocardiogram (ECG).

 

 

Sources of Information and Basis for Decision

 

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

 

ACC/AHA Guidelines for Ambulatory Electrocardiology, Journal of the American College of Cardiology, Vol. 34, No.3, Sept. 1999:912-48.

 

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

 

FCSO 32818, Long-Term Wearable Electrocardiographic Monitoring (WEM), 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Holter Monitors, Cardiac Event Recorders and Insertable Loop Recorders (2005). Cardiovascular Consultants Medical Group. Retrieved September 27, 2005, from http://www.healthyhearts.com/monitor.htm.

 

Joshi, A.K., Kowey, P.R., Prystowsky, E.N., Benditt, D.G., Cannom, D.S., Pratt, C.M., et al. (2005). First Experience With a Mobile Cardiac Outpatient Telemetry (MCOT) System for the Diagnosis and Management of Cardiac Arrhythmia [Electronic version]. The American Journal of Cardiology 95(7), 878-881.

 

Rothman, Steven A., M.D., et al. The Diagnosis of Cardiac Arrhythmias: A Prospective Multi-Center Randomized Study Comparing Mobile Cardiac Outpatient Telemetry Versus Standard Loop Event Monitoring. Journal of Cardiovascular Electrophysiology. 2007;18(3):241-247

 

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.

 

 

01/01/2013

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

LCD LONG-TERM WEARABLE ELECTROCARDIOGRAPHIC MONITORING (WEM) (L32820)