Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27520

Real-Time, Outpatient Cardiac Monitoring

L27520

CPT codes, descriptions and other data only are copyright 2007 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.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-4, Chapter 15, Section 10.4.3

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Real-time, outpatient cardiac monitoring is an automatically activated system that requires no patient intervention to either capture or transmit an arrhythmia when it occurs. Upon arrhythmia detection, the device utilizes the standard telephone line or wireless communications and transmits the ECG waveform to the receiving center. The patient's physician is made aware of arrhythmias based on pre-determined notification criteria, tailored to the patient by the physician.

In this system, the patient wears a small telemetry transmitter that sends the ECG to the computer with modem where the real-time analysis occurs. When the ECG violates certain alarm limits, the ECG strip is automatically sent to the receiving center via the computer modem or wireless communication. The receiving center also has the capability to receive and review a patient's ECG strip in real-time, at any time during the episode of monitoring. Qualified technicians perform ECG surveillance 24 hours a day. The patient's physician is notified of ECG abnormalities based on the notification criteria. This rapid arrhythmia recognition and physician notification allows timely intervention. In addition, this system provides an analysis and report of 24 hours of monitoring, similar to Holter studies. Therefore, the concomitant use of cardiac surveillance, Holter monitoring, and /or event monitoring would not be necessary.

Covered Indications

At this time, Medicare coverage for this service is limited to a very select patient population who have demonstrated a need for cardiac monitoring, and for whom all the following pertain:

1. There is low likelihood of a potentially life-threatening cardiac event.
   
   
2. Other testing and/or monitoring has been unrevealing or is inappropriate for the patient.
   
   
3. It is anticipated that the results of this service would provide diagnostic and treatment information.

Real-time, outpatient cardiac monitoring may be indicated for the following patients who have demonstrated a need for cardiac monitoring (and meet the above requirements):

• Patients who require monitoring for known, non life-threatening arrhythmias, such as paroxysmal atrial fibrillation, other paroxysmal supra-ventricular arrhythmias, evaluation of various bradyarrhythmias and intermittent bundle branch block
• Patients recovering from cardiac surgery who have had documented atrial arrhythmias
• Patients with symptomatic underlying structural disease
• Patients with no structural heart disease but who have recurrent severe symptoms (i.e., recurrent syncope), in whom all testing is negative and an implantable event recorder is contemplated
• Patients with uncontrolled atrial fibrillation post-pneumonectomy

Coverage Limitations

Real-time, outpatient cardiac monitoring is contraindicated for use in patients at high risk of developing sustained ventricular tachycardia or ventricular fibrillation and would be more appropriately cared for in a hospital setting.

This service is not indicated for all patients with arrhythmias. It should be used only in circumstances where traditional Holter monitoring or cardiac event recording is not expected to provide adequate information or has been unrevealing.

In addition, this system is NOT for patients with mild to moderate symptoms of "palpitations" or "weakness".

This system is also NOT indicated for use as a screening tool.

Use of cardiac surveillance and Holter or event monitoring for the same patient on the same day is not medically necessary.

Diagnostic Tests and X-Rays

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient's medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
   
   
4. Documentation supporting the medical necessity of the monitoring must be maintained by the referring physician and be available to the contractor upon request.
   
   
5. The following documentation supports the technical component of the service and must be maintained by the monitoring entity and be available to the contractor upon request:
   
   • The order for the service
   • Appropriate patient selection criteria as outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy
   • Copies of transmitted ECG and response by the monitoring entity
   • Daily reports to the referring physician
   • Physician contacts and responses
   • Summary report at the end of the monitoring episode

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

This monitoring is expected to not be reported more than once in a 30 day period.  Claims reporting more than one monitoring episode in a 30 day period are subject to denial. 

This monitoring service is expected to not be reported more than twice in a twelve month period. Claims reporting more than two monitoring episodes in a twelve month period are subject to denial.

The cardiac problems experienced by patients receiving this service, and the potential sequelae or complications of these problems, may be very intricate and complex. In order to ensure quality of care to the Medicare beneficiaries receiving this service, this service should be ordered and interpreted by providers with experience in caring for these types of patients. These providers should also possess a thorough knowledge of the patient receiving the service. As always, concerns or issues uncovered by this contractor will be referred to the appropriate Medicare Quality Improvement Organization.

For services provided by an independent diagnostic testing facility (IDTF):

The procedure must be performed under the general supervision of a physician specializing in cardiology or internal medicine. In general supervision, the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies, is the continuing responsibility of the physician.

National or state-level training and certification requirements for nonphysician personnel include:

1. Certified Cardiographic Technician (CCT) (Cardiovascular Credentialing International (CCI))
   
   
2. Registered nurse with current certification in Advanced Cardiac Life Support (ACLS)
   
   
3. Emergency Medical Technician (EMT) with current ACLS certification

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups which includes representatives from General Surgery, Cardiology, Family Practice and Emergency Medicine.

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27520

05/22/2008

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