Medical Policy Bulletin

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Title:

Ambulatory, Real-Time Cardiac Surveillance System

Policy #:

07.02.07d

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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the medical necessity criteria for an ambulatory, real-time cardiac surveillance system.

Description

An ambulatory, real-time cardiac surveillance system is an automatically activated device that requires no active intervention to capture or transmit an arrhythmia when it occurs. Upon arrhythmia detection, the device utilizes a standard telephone line to transmit the electrocardiogram (ECG) waveform to a receiving center where qualified technicians perform ECG surveillance 24 hours a day. The individual’s physician is made aware of the arrhythmia based on predetermined notification criteria. This system requires the individual to wear a small telemetry transmitter that sends an ECG waveform to a computer, where real-time analysis occurs. When the rhythm violates preset alarm limits, the ECG strip is automatically sent to the receiving center via modem. This rapid arrhythmia recognition and physician notification allows for timely intervention. Similar to Holter studies, this system provides an analysis and report for 24 hours of monitoring.

Policy

An ambulatory, real-time cardiac surveillance system is considered medically necessary and, therefore, covered for individuals who meet all of the following criteria: The individual has little likelihood of a malignant cardiac event (eg, no history of ventricular fibrillation [VF] or sustained ventricular tachycardia [VT]). Other testing and/or monitoring (eg, electrocardiogram [ECG] or 24-hour Holter monitoring) has been unrevealing or is inappropriate. Results of this system are expected to provide diagnostic and treatment information for an individual with any of the following conditions: A previously diagnosed non–life-threatening arrhythmia: Atrial fibrillation Other supraventricular arrhythmias Various bradyarrhythmias Intermittent bundle branch block A symptomatic underlying structural heart disease (eg, congenital heart defect, hypertrophic cardiomyopathy, mitral valve prolapse, coronary artery anomaly) No structural heart disease revealed on preliminary testing, but recurrent severe symptoms that may require an implantable event recorder for assessment Uncontrolled atrial fibrillation post-pneumonectomy Post-coronary artery bypass graft surgery or valve replacement surgery with documented atrial arrhythmias An ambulatory, real-time cardiac surveillance system is contraindicated for individuals who would be better cared for in a hospital setting and who meet one of the following criteria: A history of sustained VT A documented occurrence of VF At risk for sustained VT, as indicated by any of the following criteria: An ejection fraction of less than 30 percent, with a widened QRS waveform on ECG Unstable angina as defined by chest pain at rest, a new onset of angina, or a change in existing patterns of angina A candidate for heart valve surgery Mild-to-moderate symptoms (eg, palpitations, weakness) Moderate-to-severe symptoms (eg, syncope, near syncope) with underlying structural disease and a high likelihood of developing sustained VT or VF A family history of sustained VT or VF Monitoring is considered not medically necessary and, therefore, not covered beyond 21 consecutive days. Monitoring is also limited to two episodes in 12 months. BILLING GUIDELINES Participating network providers will be reimbursed in accordance with provider contracts. To report the professional component, participating network providers must report the NOC code 93799 with Modifier 26 (93799-26). For paper billers: Include “ECG arrhythmia detection and alarm system” in the shaded area of field 24A of the CMS-1500 (08/05) form. For electronic billers: Submit the NOC code in the HCPCS/CPT data element 2400/SV101-2 (837P) and report the text in 2400/NTE02 when NTE01 equals ADD. Text can also be reported at the claim level, 2300/NTE. The professional component includes review and interpretation of each 24-hour cardiac surveillance period, as well as 24-hour availability and response to monitoring events within a course of treatment that includes up to 21 consecutive days of cardiac monitoring (ie, "monitoring period"). This code is eligible once in a monitoring period of up to 21 consecutive days. The date the individual is initially placed on the monitor must be reported as the date of service. The monitoring period (one to 21 consecutive days of cardiac monitoring) is reported as a unit of one. Any additional claims for procedure code 93799-26 – “ECG arrhythmia detection and alarm system,” within a monitoring period (one to 21 days after an initial service) will be denied. Please refer to the Coding Table in this policy for the list of International Classification of Disease (ICD) diagnosis codes that are considered medically necessary and, therefore, covered for an ambulatory, real-time cardiac surveillance system.

Guidelines

MEDICARE This policy is consistent with Medicare's coverage criteria. Payment methodologies may vary. ALL PRODUCTS Subject to the terms and conditions of the applicable benefit contract, ambulatory, real-time cardiac surveillance system services are covered under the medical benefit of the Company’s products when the medical necessity criteria listed in the medical policy are met. Ambulatory, real-time cardiac surveillance system services do not require precertification or referrals for any line of business. The Company reserves the right to conduct reviews and audits of services provided to our members for ambulatory cardiac surveillance monitoring, particularly when it exceeds 21 consecutive days or is reported more than twice in a 12-month period. This review/audit process may be performed pre- or post-payment and can include, but is not limited to, a review of all services related to the claim, adequacy of the documentation, and the proper usage of all reportable billing codes.

References

Highmark Medicare Services. Local Coverage Determination (LCD). M-60D: Real-time, outpatient cardiac monitoring. [Highmark Medicare Services Web site]. Original: 02/11/02. (Revised: 01/15/06). Available at: http://www.highmarkmedicareservices.com/policy/partb/m1/m60d.html. Accessed October 23, 2007. US Food and Drug Administration (FDA). Center for Devices and Radiologic Health. CardioNet arrhythmia detector and alarm. 510(k) summary. [FDA Web site]. 04/25/06. Available at: http://www.fda.gov/cdrh/pdf5/K053263.pdf. Accessed October 23, 2007.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	93228, 93229 TO REPORT THE PROFESSIONAL COMPONENT OF THIS SERVICE, PARTICIPATING NETWORK PROVIDERS MUST REPORT THE FOLLOWING CODE WITH MODIFIER 26 93799
ICD Procedure	N/A
ICD Diagnosis	426.0: Atrioventricular block, complete 426.10: Unspecified atrioventricular block 426.11: First degree atrioventricular block 426.12: Mobitz (type) II atrioventricular block 426.13: Other second degree atrioventricular block 426.2: Left bundle branch hemiblock 426.3: Other left bundle branch block 426.4: Right bundle branch block 426.50: Unspecified bundle branch block 426.51: Right bundle branch block and left posterior fascicular block 426.52: Right bundle branch block and left anterior fascicular block 426.53: Other bilateral bundle branch block 426.54: Trifascicular block 426.6: Other heart block 426.7: Anomalous atrioventricular excitation 426.81: Lown-Ganong-Levine syndrome 426.82: Long QT syndrome 426.89: Other specified conduction disorder 426.9: Unspecified conduction disorder 427.0: Paroxysmal supraventricular tachycardia 427.31: Atrial fibrillation 427.32: Atrial flutter 427.61: Supraventricular premature beats 427.81: Sinoatrial node dysfunction 427.89: Other specified cardiac dysrhythmias 780.2: Syncope and collapse
HCPCS Level II	N/A
Revenue Codes	N/A

Cross References

Version Effective Date: 01/01/2010