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Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.02.21k

Policy

AMBULATORY ELECTROCARDIOGRAPHY (AECG) MONITORING, INCLUDING MOBILE CARDIAC OUTPATIENT TELEMETRY (MCOT) MONITORING

Any of the following clinical criteria for AECG monitoring, including MCOT monitoring, must be met to be considered medically necessary and, therefore, covered. In addition, the monitoring device's criteria listed below must also be met to be considered medically necessary and, therefore, covered.

MEDICALLY NECESSARY CLINICAL CRITERIA

 Adult Clinical Criteria

AECG monitoring, including MCOT monitoring, is considered medically necessary and, therefore, covered under any of the following circumstances:
  • To establish the diagnosis for recurrent symptoms/conditions related to arrhythmia, such as presyncope, syncope, palpitations, shortness of breath, chest pain, or dizziness, that are less frequent than once every 48 hours, when the diagnosis has not been determined by indicated diagnostic work-up (e.g., complete clinical history and physical examination, standard 12-lead electrocardiography [ECG], cardiac imaging)
    • The ordering professional provider must document the prior testing performed and the results
  • To monitor individuals who have had surgical or catheter ablation of atrial fibrillation (AF) when discontinuation of systemic anticoagulation is being considered
  • To monitor individuals with cryptogenic stroke who have a negative work-up for AF when the etiology of the symptoms/conditions of arrhythmia has not been determined after indicated diagnostic workup (e.g., a complete clinical history and physical examination, standard 12-lead ECG, cardiac imaging)
  • To monitor the effectiveness of antiarrhythmic drug dosages in individuals at risk of an arrhythmia in whom baseline frequency of an arrhythmia has been characterized as reproducible and of sufficient frequency to permit analysis
  • To assess function of pacemakers or implantable cardioverter defibrillators (ICD) in order to evaluate any of the following:
    • Frequent symptoms of palpitation, syncope, or near syncope to assess device function to exclude myopotential inhibition and pacemaker-mediated tachycardia
    • Frequent symptoms of palpitation, syncope, or near syncope to assist in programming parameters such as rate-responsivity and automatic mode switching
    • Suspected component failure or malfunction when device interrogation is not definitive in establishing a diagnosis
    • Response to adjunctive pharmacologic therapy in individuals receiving frequent ICD therapy
  • To evaluate individuals with idiopathic hypertrophic or dilated cardiomyopathies to detect arrhythmias
  • To evaluate individuals for silent myocardial ischemia with documented coronary artery disease by detecting ischemic ECG changes
Pediatric Clinical Criteria

In accordance with the American College of Cardiology/American Heart Association, pediatric AECG monitoring, including MCOT monitoring, is considered medically necessary and, therefore, covered for the evaluation of the following indications:
  • Syncope, near syncope, or dizziness with recognized heart disease, previously documented arrhythmia, or pacemaker dependency
  • Syncope or near syncope associated with exertion when the cause is not established by other methods
  • Hypertrophic or dilated cardiac myopathies
  • Possible or documented long QT syndromes
  • Palpitations in individuals with prior surgery for congenital heart disease and significant residual hemodynamic abnormalities
  • Antiarrhythmic drug efficacy
  • Asymptomatic congenital atrioventricular (AV) block, nonpaced
MEDICALLY NECESSARY MONITORING DEVICE CRITERIA
Monitoring Device Criteria (Adults and Pediatrics)

Continuous AECG monitoring (24- or 48-hour Holter monitoring) is considered medically necessary and, therefore, covered for either of the following indications:
  • Results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the individual about and beyond that provided by standard 12-lead ECG.
    • The ordering professional provider must document the prior testing performed and the results.
  • Standard 12-lead ECG is documented in the medical record to be unlikely to capture and record an arrhythmia.
External cardiac event detection monitoring (e.g., external loop monitoring) is considered medically necessary and, therefore, covered for either of the following indications:
  • Results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the individual about and beyond that provided by continuous 24- or 48-hour Holter monitoring.
    • The ordering professional provider must document the prior testing performed and the results.
  • Continuous 24- or 48-hour Holter monitoring is documented in the medical record to be unlikely to capture and record an arrhythmia.
External cardiac event detection monitoring must be attended 24 hours a day, 7 days a week.

External cardiac event detection monitoring devices that are patient activated are not indicated for individuals who are unresponsive, comatose, severely confused, or otherwise unable to recognize symptoms or activate the recorder device.

Symptomatic transient cardiac arrhythmias are typically detected within 2 months of external cardiac event detection monitoring. However, an extended period of monitoring may be considered for coverage by the Company in certain circumstances (i.e., efficacy of newly introduced antiarrhythmic medications, efficacy of cardiac medications post-ablation, severe symptoms of arrhythmia, and cryptogenic stroke).

Continuous AECG monitoring for periods greater than every 48 hours (e.g., Zio® Patch) is considered medically necessary and, therefore, covered for either of the following indications:
  • Results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the individual about and beyond that provided by continuous 24- or 48-hour Holter monitoring and/or external cardiac event detection monitoring (e.g., external loop monitoring).
    • The ordering professional provider must document the prior testing performed and the results.
  • Continuous 24- or 48-hour Holter monitoring and/or external cardiac event detection monitoring (e.g., external loop monitoring) is documented in the medical record to be unlikely to capture and record an arrhythmia.
Mobile cardiac outpatient telemetry monitoring of non–​life-threatening arrhythmias for up to two episodes of up to 30 consecutive days in a 12-month period is considered medically necessary and, therefore, covered for either of the following indications:
  • Results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the individual about and beyond that provided by continuous 24- or 48-hour Holter monitoring and/or external cardiac event detection monitoring (e.g., external loop monitoring).
    • The ordering professional provider must document the prior testing performed and the results
  • Continuous 24- or 48-hour Holter monitoring and/or external cardiac event detection monitoring (e.g., external loop monitoring) is documented in the medical record to be unlikely to capture and record an arrhythmia
Cardiac event detection monitoring (implantable loop monitoring) is considered medically necessary and, therefore, covered for either of the following indications:
  • Results of this testing will provide diagnostic and/or treatment information useful in the ongoing management of the individual about and beyond that provided by continuous 24- or 48-hour Holter monitoring and/or external cardiac event detection monitoring (external loop monitoring)
    • The ordering professional provider must document the prior testing performed and the results
  • Continuous 24- or 48-hour Holter monitoring and/or external cardiac event detection monitoring (external loop monitoring) is documented in the medical record to be unlikely to capture and record an arrhythmia
EXPERIMENTAL/INVESTIGATIONAL

All other uses of AECG monitoring, including MCOT monitoring, are considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

The use of AECG monitoring managed through a mobile application for smartphones (e.g., AliveCor, KardiaMobile) and smartwatches, is considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

When the etiology of the symptoms/conditions of arrhythmia has not been determined after a 24- or 48-hour continuous Holter monitoring or other appropriate AECG monitoring including MCOT monitoring, the ordering professional provider must document the prior testing performed and the results.

ELIGIBLE FOR REIMBURSEMENT

TECHNICAL AND PROFESSIONAL
AECG Monitoring, Including MCOT Monitoring

The professional component for AECG monitoring, including MCOT monitoring, is for the review and interpretation with report by a professional provider. When a technician, who is employed by the professional provider, retrieves and reviews data from a secure server via modem, the service is included in the reimbursement for the professional component.

External Loop Monitoring and MCOT Monitoring

The technical component (e.g., technical support for connection, individual instructions for use, remote data acquisition, technical analysis and transmission of daily and emergent data reports as prescribed by the professional provider) for external loop monitoring and MCOT monitoring is only reimbursable to the monitoring center or independent diagnostic testing facility that is gathering and transmitting the data to the professional provider for review.

Implantable Loop Monitoring

For implantable loop monitoring, the technical component is only reimbursable to an independent diagnostic testing facility that is gathering and transmitting data to professional provider for review.

EXTERNAL CARDIAC EVENT DETECTION MONITORING, MCOT MONITORING, AND IMPLANTABLE LOOP MONITORING
Reimbursement for external cardiac event detection monitoring, MCOT monitoring, and implantable loop monitoring, electronic analysis (e.g., the retrieval, viewing, printing, and saving of an ECG associated with a patient-activated syncopal event) of the data is allowed once in a 30-day period, regardless of the number of events or recordings that occur during this time frame.

NOT ELIGIBLE FOR REIMBURSEMENT

AMBULATORY ELECTROCARDIOGRAPHY MONITORING, INCLUDING MCOT MONITORING
The use of multiple forms of AECG including MCOT monitoring provided to the same individual on the same day is not eligible for coverage or reimbursement by the Company.

BILLING REQUIREMENTS

When reporting AECG monitoring, including MCOT monitoring due to an abnormal ECG/EKG
(International Classification of Diseases [ICD]-10 code R94.31), providers must report one of the ICD-10 codes for symptoms/conditions of arrhythmia (R06.00, R06.02, R07.89, R07.9, R42, R55 ) in the secondary diagnosis position on the claim.

When reporting AECG monitoring, including MCOT monitoring, when the discontinuation of systemic anticoagulation is being considered (ICD-10 Z79.01), providers must report one of the ICD-10 codes for atrial fibrillation (I48.0, I48.2, I48.91) in the secondary diagnosis position on the claim.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

The use of ambulatory electrocardiography (AECG) monitoring, including mobile cardiac outpatient telemetry (MCOT) monitoring devices, to diagnose and treat suspected arrhythmia should not be substituted for more conventional methods of diagnosis, such as a clinical history, physical examination, and standard electrocardiogram (ECG) and rhythm strip.

Ambulatory electrocardiography monitoring, including MCOT monitoring, should only be reported for individuals being evaluated as outpatients and not used for review and interpretation of ECG rhythm strips generated by inpatient cardiac monitors or telemetry. It should not be reported for individuals in hospitals, emergency rooms, skilled nursing facilities, or other specialized facilities.

Providers of monitoring centers should be capable of receiving and recording transmissions 24 hours a day, 365 days a year while the individual is wearing the device. This includes receipt of the ECG signal, as well as a voice transmission that relates any associated symptoms. The transmission should be received by a technician, nurse, or physician trained in the interpretation of ECGs and abnormal rhythms. A professional provider should be available for immediate consultation 24 hours a day to review the transmission in case of significant symptoms or ECG abnormalities. Monitoring centers should also be capable of notifying an individual's attending professional provider immediately, when indicated.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, AECG monitoring, including MCOT monitoring, is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for AECG monitoring, including MCOT monitoring.

Description

There are a wide variety of devices available for ambulatory cardiac monitoring. The primary purpose of ambulatory electrocardiography (AECG) monitoring is the evaluation of suspected arrhythmias that have not been detected in office- or hospital-based monitoring, generally while the individual is engaged in daily activities, including sleep. These devices differ in the types of monitoring leads used, the duration and continuity of monitoring, the ability to detect arrhythmias without individual intervention, and the mechanism of delivery or information from the individual to the clinician. Traditionally, these devices may be used for the evaluation of symptoms suggestive of arrhythmias such as syncope or palpitations. Other common clinical uses include the detection of atrial fibrillation (AF) in individuals who have undergone cardiac ablation of AF, or who have a history of cryptogenic stroke; the assessment of treatment response to antiarrhythmic therapy; the assessment of pacemaker and implantable cardioverter defibrillator (ICD) function; the evaluation of idiopathic hypertrophic cardiomyopathy; or the evaluation for suspected myocardial ischemia.

CONTINUOUS AMBULATORY ELECTROCARDIOGRAPHY (AECG) MONITORING (HOLTER MONITORING)

Continuous AECG monitoring (Holter monitoring) is a noninvasive test in which the electrocardiogram (ECG) is continuously recorded over an extended period of time, typically 24 to 48 hours, to evaluate fairly frequent symptoms (e.g., palpitations, dizziness, syncope) suggestive of cardiac arrhythmias. A Holter monitor is about the size of a large deck of cards. It can be clipped to a belt or carried in a pocket. Wires connect the device to electrodes that are placed on specified areas of the chest using sticky patches. These electrodes (sensors) detect the heart's electrical signals, and the monitor records heart rhythm. The heart's activity is recorded rather than transmitted. Holter monitoring, however, may be ineffective in detecting arrhythmias if an individual experiences infrequent symptoms. Therefore, the sensitivity of Holter monitoring is low for the detection of arrhythmias that are intermittent.

POST-EVENT CARDIAC DETECTION MONITORING

A cardiac event detection monitor can be either a hand-held device or worn on a wrist. When the individual feels a symptom or irregular heartbeat, the monitor is placed on the chest and a recording button is activated. The back of this device has small metal discs that function as the electrodes. If the monitor is worn on a wrist, a button is pressed to record. Some of these types of cardiac event detection monitors typically only record the rhythm that occurs with an individual's perceived symptoms and not those events that are asymptomatic. These monitors, referred to as post-event monitors, are of limited utility, as they do not include a memory loop, so they have no memory to allow recording of the rhythm before the device is activated. The device transmits ECG data telephonically to a central monitoring center and then is uploaded to a secured computer for analysis.

For example, in September 2011, the US Food and Drug Administration (FDA) gave 510(k) approval to the REKA E100™ system, a noncontinuous single-lead cardiac event detection monitor. This device is the size of a hockey puck and weighs no more than a few ounces. There are two options depending on the individual's circulation. First, a zero-lead device that is separate from the body and may be carried in a purse or coat pocket. If an individual's circulation is determined to be inadequate, a single electrode lead that the individual connects to the device at the time of an event is another option. The zero-lead device records an event by individual activation and can record and store up to 2,000 readings. The individual has the choice of sending stored event information to the monitoring center across a phone application or the internet on their computer. The monitoring center provides the EGG data to the referring professional provider for evaluation.

EXTERNAL CARDIAC EVENT DETECTION MONITORING (EXTERNAL LOOP MONITORING)

External cardiac event detection monitoring (external loop monitoring), typically involves long-term (30 days or more) monitoring of the heart rhythm of an individual with significant, but very infrequent, symptoms that are suggestive of transient cardiac arrhythmia. The infrequency of the arrhythmia makes it difficult to identify on a 24- or 48-hour continuous Holter monitor.

External cardiac event detection monitoring (external loop monitoring) is initiated in either the office or the home setting. The device is an ECG recording monitor with a continuous loop that attaches to the chest with electrodes, and is typically worn up to 1 month or longer. The device records the ECG in a continuous manner, but stores only a brief period of ECG recording in memory. When the event marker is activated at the time of a symptom, the device's looping memory is individually programmed to record an ECG 30 to 90 seconds prior to activation, and the next minute or so after activation. In addition to patient-activated monitoring, autotriggering monitoring is available. Autotriggering loop monitors have the capability to be automatically activated in the case of a predefined arrhythmia, such as asystole of greater than 3 seconds, and/or other variable rate and rhythm intervals. Autotriggering loop monitors do not rely on an individual's ability to activate and, as a result, are able to capture asymptomatic, in addition to symptomatic events.

Information may be stored in the device and later reviewed or transmitted from the monitoring device to a receiving monitoring center where the data is reviewed. The transmission ranges from the simple, analog dial-in transtelephonic system, to a cellular phone link, or a wireless link or internet based in-home computer that captures and stores ECG data. Currently, no one system is proven to be superior to another.

A representative example of a patient-activated external looping monitor includes Zio® Event Card (iRhythm Technologies, Inc., San Francisco, CA). In June 2008, the FDA gave 510(k) approval to the a non-continuous real-time recording device Zio® Event Card (iRhythm Technologies, Inc., San Francisco, CA) that can be worn up to 30 days. This device can be worn under clothing (including during sleep), as it weighs less than 2 ounces and is similar in size to a standard credit card. Upon activation by the individual, the card is able to record the previous 45 seconds of ECG activity into memory plus the first 15 seconds after the button is pushed. This is made possible because this device continuously scans for ECG activity but only records upon symptom activation. After the device is activated, the individual is responsible for calling the iRhythm National Clinical Center (NCC), which then instructs the individual on sending the event over the phone line.

Other devices for external loop monitoring include King of Hearts Express® AF (Istromedix®, San Diego, CA), Looping Multi-Event Monitor (CardioNet Inc., Conshohocken, PA), and LifeStar AF Express (Life Watch, Buffalo Grove, IL).

CONTINUOUS AMBULATORY ELECTROCARDIOGRAPHY MONITORING (AECG) FOR PERIODS GREATER THAN 48 HOURS

Despite the clinical utility of 24- or 48-hour continuous Holter monitoring in clinical cardiology, issues such as diagnostic yield and individual compliance have prompted the development of ultra-portable devices for extended monitoring, referred to as ECG patch monitors. For example, the FDA approved the Zio® Patch, Model Z100 and the Zio® Patch (iRhythm Technologies Inc., San Francisco, CA) in May 2009 and February 2012, respectively. Both approvals carry the same indication for use as a prescription-only, single-use, continuous recording ECG monitor that can be worn for up to 14 days. It is indicated for use on individuals who experience transient symptoms such as syncope, palpitations, shortness of breath, or chest pains. The Zio® Patch system is most analogous to a 24- or 48-hour continuous Holter monitor that records and stores information. The available published peer-reviewed literature suggests that Zio® Patch typically detects a greater number of arrhythmias during extended follow-up than 24- or 48-hour Holter monitor. This system consists of a patch worn over the left pectoral region of the body that records continuously for up to 14 days, while the individual keeps a symptom log. At the end of the recording period, the individual mails back the recorder in a prepaid envelope to a central center where the ECG data are analyzed via a proprietary algorithm using the Zio ECG Utilization Service (ZEUS) System. A full report is provided to the referring professional provider for interpretation and clinical management.

Other similar continuous AECG monitoring devices with recording periods greater than 48 hours include myPatch® (Dms-Service Llc., Santa Monica, CA), Stealth™ Monitor (Cardiac Insight Inc., Bellevue, WA).

MOBILE CARDIAC OUTPATIENT TELEMETRY (MCOT) MONITORING

Although many monitors have automatic activation capability and allow the individual to transmit data to a monitoring center, they do not automatically transmit the data at the time of occurrence to an attended monitoring center. An MCOT is an automatically activated device that requires no active intervention to capture or transmit an arrhythmia when it occurs, although data can also be recorded through patient activation. Mobile cardiac outpatient telemetry is the real-time transmission of the individual's cardiac activity to a receiving monitoring center which converts this electronic transmission into a visible image that is constantly and continuously displayed on a monitor in the receiving monitoring center so that qualified technicians located in the receiving monitoring center can provide immediate and accurate surveillance of the individual's cardiac activity 24 hours a day, 7 days a week. The individual's referring professional provider is made aware of arrhythmias based on predetermined notification criteria specific to that individual. The ability to respond immediately when clinically important arrhythmias occur is the major advantage real-time MCOT monitoring.

For example, CardioNet® Inc. (Conshohocken, PA) offers MCOT monitoring. In this system, the individual wears a three-lead sensor, which constantly communicates with the CardioNet® monitor, a lightweight unit that can be carried in a pocket or a purse. When an arrhythmia is detected according to preset parameters, the ECG is automatically transmitted to a central CardioNet® service center, where the ECG is immediately interpreted, with results sent to the referring professional provider. The referring professional provider can request the level and timing of response, ranging from daily reports to stat results. Other systems for MCOT monitoring include the HEARTLink II™ system (Cardiac Telecom Corp., Greensburg, PA), the Vital Signs Transmitter (VST™; Biowatch Medical, Columbia, SC), and the LifeStar™ Ambulatory Cardiac Telemetry (ACT) system (Card Guard Scientific Survival Ltd., Israel).

In February 2014, the FDA gave 510(k) approval to the Nuvant Mobile Cardiac Telemetry (MCT) System, now known as SEEQ ​MCT (Medtronic, Inc. Minneapolis, MN). SEEQ™ MCT is a one-time use, wearable adhesive cardiac sensor that can be worn up to 30 days. SEEQ™ MCT is intended to continuously measure, record, and periodically transmit physiological data. The wearable, wireless-enabled sensor continuously monitors the heart and automatically transmits rhythm abnormalities to the cardiographic technicians at the Medtronic Monitoring Center. Individuals can also trigger transmission of ECGs when they experience cardiac symptoms by using the trigger button. Reports are provided to the referring professional providers for review and analysis. This system is indicated for those individuals who require monitoring for the detection of nonlethal cardiac arrhythmias such as, but not limited to, supraventricular tachycardias (SVTs) (e.g., atrial fibrillation, atrial flutter, paroxysmal SVTs), ventricular ectopy, bradyarrhythmias, and conduction disorders.

In August 2012, the FDA gave 510(k) clearance to the BodyGuardian Remote Monitoring System™ (Price® Inc., Minneapolis, MN). The monitoring system continuously detects and records a variety of physiologic data including ECG tracing, respiratory rate, and activity level for up to 30 days. The data is delivered securely from the BodyGuardian Control Unit to the BodyGuardian Connect smartphone device. In turn, the individual data is wirelessly delivered to the Price® CarePlatform, a cloud-based mobile health (mHealth) platform that collects real-time data from devices and delivers information to the referring professional providers.

In November 2011, the FDA gave 510(k) clearance to the VectraplexECG™ System (VectraCor Inc., Totowa, NJ, and Maple Grove, MN) is a real-time continuous MCOT device to measure ischemic ECG changes that can be indicative of a myocardial infarction (MI). This device uses the Internet to communicate real-time ECG changes to the professional provider. The individual is hooked up to a mini-tablet by either five electrodes, which communicate 15-lead ECG data, or 10 electrodes that communicate 12-lead ECG data. Although this system is primarily intended to monitor for ischemia, the continuous ECG monitoring would presumably detect rhythm disturbances, as well as ischemic changes.

CARDIAC EVENT DETECTION MONITORING (IMPLANTABLE LOOP MONITORING)

A cardiac event detection monitor (implantable loop monitor) is an implantable device that is inserted subcutaneously, usually in a left pectoral or mammary location. The electrodes that sense the heart's activity are on the surface of the device, so no transvenous leads are necessary. Prior to the device insertion, the monitor may be initially programmed. For a patient-activated monitoring system, when symptoms occur, the individual uses a hand-held activator to store a segment of the ECG in the device's memory. Auto-triggering technology can be adapted to the implantable cardiac loop monitoring devices. For example, implantable autotrigger loop monitors have the capability to be automatically activated in the case of a predefined arrhythmia such as asystole of greater than 3 seconds, and/or other variable rate and rhythm intervals. The device's looping memory is individually programmed to record an ECG 30 to 90 seconds prior to activation. The newest generations of these devices allow remote transmission of data, and have a projected longevity of the device's battery for up to 3 years. The professional provider utilizes a programmer to retrieve, display, and print stored data. Implantable cardiac loop monitors have the capacity to record cardiac events for approximately 3 years and to store many separate events.

For example, the Reveal® XT ICM (Medtronic Inc., Minneapolis, MN) is an implantable memory loop device cleared for marketing by the FDA in 2008 that allows patient-activated rhythm recording, rhythm recording at prespecified time intervals, or autotriggered rhythm recording. In February 2014, the FDA cleared for marketing the Reveal LINQ™, a miniaturized implantable memory loop device with an approximate volume of​ 1 mL that includes autotriggered or patient-activated rhythm recording.

The current clinical use of an implantable cardiac loop monitor involves the evaluation of transient, recurrent symptoms of possible arrhythmic origin, after a trial of cardiac event detection monitoring (i.e., external loop monitoring) does not yield a definitive diagnosis, and long-term monitoring is needed.

AECG MONITORING MANAGED THROUGH MOBILE APPLICATIONS FOR SMARTPHONE AND SMARTWATCH TECHNOLOGY

Trans-telephonic ECG event recorder records, store and transfer single-channel electrocardiogram rhythms (e.g., KardiaMobile [previously AliveCor ECG, AliveCor Heart Monitor], KardiaBand). These devices utilize the processing power of a mobile application to obtain and analyze single-channel ECG. The device is placed on the chest or held by the individual’s hands while pressing fingers from each hand onto the electrodes to provide a single-channel ECG rhythm strip. Similar to other mobile ECG devices, the devices use a proprietary method of data transmission using acoustic waves to communicate with the mobile application where the waveform is stored, displayed, and analyzed for the presence of an irregular heart rhythm. They are designed to work in conjunction with a range of mobile platforms, including iPhone, iPad, and Android devices and may be obtained without a prescription. AECG monitoring managed through mobile applications for smartphone and smartwatch technology are intended for use by healthcare professionals, individuals with known or suspected heart conditions, and health-conscious individuals. These devices provide a single-lead ECG and cannot provide the level and detail obtained by the typical 12-lead ECG performed by professional providers.

The accuracy of smartphone-based applications intended to measure heart rate varies widely. Investigators evaluated the accuracy of four randomly selected, commercially available applications intended to measure heart rate using two types of smart phones (iOS) (Wyss, 2017). The applications are based on photoplethysmography, an optical technique that measures light reflectance to detect blood volume changes in the microvasculature. The two contact-based applications require individuals to place a finger on the smart phone's built-in camera. Researchers randomly recruited 108 noncritical individuals who required heart rate monitoring in a chest pain unit or emergency department. They measured heart rate simultaneously using the applications on both smartphones, conventional ECG, and pulse oximetry. The researchers found differences greater than 20 beats per minute compared to ECG in more than 20% of application measurements. Noncontact applications performed worse than contact applications, especially at higher heart rates and lower body temperatures. Noncontact applications tended to overestimate higher heart rates. Further, both contact applications performed differently. Researchers could not attribute the divergent contact application performance to camera technology, age, body temperature, or heart rate itself, suggesting the application's proprietary algorithm was the cause.

In addition, there is currently a lack of evidence to support the clinical value of AECG monitoring managed through mobile applications for smartphone and smartwatch technology. Prospective, randomized controlled studies are needed to ascertain how the use of these devices would improve clinical outcomes in individuals with cardiovascular diseases/disorders.

RECOMMENDATIONS FOR AMBULATORY ELECTROCARDIOGRAPHY (AECG) TYPE

Generally, the selection of a specific AECG monitoring device is based on the frequency with which the individual’s symptoms, thought to be related to cardiac arrhythmia, occur. For example, individuals with infrequent short periods of transient symptoms recurring over longer periods of time are unlikely to be diagnosed by conventional 24- or 48-hour continuous Holter monitoring, as the likelihood of symptom-ECG correlation is very low (Brignole, 2009).

According to the American College of Cardiology (ACC)/American Heart Association (AHA) Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography (2001), there are no specific guidelines that distinguish individuals for whom it is appropriate to perform continuous monitoring from those for whom intermittent monitoring is adequate. However, when monitoring is performed to evaluate the cause of intermittent symptoms, the frequency of symptoms should dictate the type of recording. However, more recently, in 2006, the AHA/American College of Cardiology Foundation (ACCF) stated that Holter monitoring is appropriate for episodes that occur at least every day, and cardiac event detection monitoring is ideal for less frequent episodes that occur at least once a month. Implantable loop monitoring is considered the most likely technology to identify the mechanism of syncope in individuals with unexplained syncope.

PRACTICE GUIDELINES

In 2014, the ACC, AHA, and the Heart Rhythm Society (HRS) issued guidelines on the management of individuals with AF. These guidelines recommend the use of Holter or cardiac event detection monitoring if the diagnosis of the type of arrhythmia is in question or as a means of evaluating rate control.

Additionally, in 2014 the American Academy of Neurology released updated guidelines on the prevention of stroke in individuals with nonvalvular atrial fibrillation (NVAF). The guidelines make the following recommendations regarding the identification of individuals with occult NVAF:
  • Outpatient cardiac rhythm studies may be obtained in individuals with cryptogenic stroke without known NVAF in order to identify individuals with occult NVAF.
  • Cardiac rhythm studies for prolonged periods (e.g., 1 or more weeks) instead of shorter periods (e.g., 24 hours) may be obtained in individuals with cryptogenic stroke without known NVAF in order to increase the yield of identification of individuals with occult NVAF.
The use of cardiac event detection monitoring postablation is addressed in a consensus document published in 2012 by the HRS Task Force on catheter and surgical ablation for AF. This document provides general recommendations based on literature review and expert consensus. Based on such recommendations, following ablation for AF, individuals in whom discontinuation of systemic anticoagulation is being considered should consider undergoing continuous ECG monitoring. In addition, the identification of less frequent AF includes a 4-week autotrigger cardiac event detection monitor or an implantable subcutaneous monitor.

In 2011, the ACCF/AHA issued guidelines for the diagnosis and treatment of hypertrophic cardiomyopathy. Class I recommendations (i.e., conditions for which there is evidence and/or general agreement that the test is useful and effective) include 24-hour continuous AECG monitoring (Holter monitoring) or event recording monitoring for specified individuals with hypertrophic cardiomyopathy.

In the 1999 Guidelines for AECG, the ACC/AHA discuss the following as a Class I indications:
  • Symptoms that may be related to disturbances of heart rhythm
  • Efficacy of antiarrhythmic therapy
  • Pacemaker and implantable cardioverter-defibrillator (ICD) function
  • Pediatric Individuals
According to the ACC/AHA Guidelines for AECG, as in adults, selection of the method of monitoring (i.e., continuous recording versus patient-activated) for the pediatric population is predicated on the frequency and symptoms of the arrhythmia. Generally, the indications for pediatric AECG monitoring include the following:
  • The evaluation of symptoms that may be arrhythmia related
  • Risk assessment in individuals with cardiovascular disease, with or without symptoms of an arrhythmia
  • The evaluation of cardiac rhythm after an intervention such as drug therapy or device implantation
TECHNICAL AND PROFESSIONAL COMPONENTS

Ambulatory ECG technology varies among different devices. Ambulatory ECG may include technical and professional components. The technical component comprises the portion of the procedure or service performed by the monitoring center or independent diagnostic testing facility, and the equipment used for the procedure or service.

The professional component is the portion of the procedure or service performed by a professional provider, which includes the interpretation, analysis, and a detailed signed written report of the results of the procedure or service.

References

Agency for Healthcare Research and Quality (AHRQ). Technology assessment. Remote cardiac monitoring. [AHRQ Web site]. 02/14/2008. Available at: http://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id51TA.pdf. Accessed November 08, 2022. 

AliveCore. Press Release. AliveCor announces smartphone electrocardiogram demonstrates accuracy in monitoring patients’ heart Health. [AliveCor Web site]. 05/12/2012. Available at:
https://www.alivecor.com/press/press_release/alivecor-announces-smartphone-electrocardiogram-demonstrates-accuracy-in-monitoring-patients-heart-health/. Accessed November 8, 2022. 

American Stroke Association. Dilated cardiomyopathy. [American Stroke Association Web-site]. Available at: Dilated Cardiomyopathy (DCM) | American Stroke Association. Accessed November 8, 2022. 

Balmelli N, Naegeli B, Bertel O. Diagnostic yield of automatic and patient-triggered ambulatory cardiac event recording in the evaluation of patients with palpitations, dizziness, or syncope. Clin Cardiol. 2003;26(4):173-6.

Barrett PM, Komatireddy R, Haaser S, et al. Comparison of 24-hour Holter monitoring with 14-day novel adhesive patch electrocardiographic monitoring. Am J Med. 2014;127(1):95-7.

Brignole M, Vardas P, Hoffman E, et al. Indications for the use of diagnostic implantable and external ECG loop recorders​. Europace. 2009;11(5):671-687. Available at: Indications for the use of diagnostic implantable and external ECG loop recorders - PubMed (nih.gov). Accessed Nobember 8, 2022. 

Calkins H, Hindricks G, Cappato R. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. [Heart Rhythm Society Web site]. October 2017. Available at:
https://www.heartrhythmjournal.com/article/S1547-5271(17)30590-8/fulltext. Accessed November 8, 2022. 

Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol. 2012;33(2):171-257.

CardioNet. CardioNet MCOT. [CardioNet Web site]. Available at: CardioNet MCOT™ Monitor - CardiacMonitoring.com​.  Accessed November 8, 2022. 

Centers for Medicare & Medicaid Services (CMS). Decision memo for electrocardiographic services (CAG-00158N). [CMS Web site]. 08/26/2004. Available at:
https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=89&DocID=CAG-00158N&generalError=Thank+you+for+your+interest+in+the+Medicare+Coverage+Database.+You+may+only+view+the+page+you+attempted+to+access+via+normal+usage+of+the+Medicare+Coverage+Database.&bc=gAAAABAACAAAAA==&. Accessed November 08, 2022.​

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).20.15: Electrocardiographic services. [CMS Web site]. 08/26/2004. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=179&ncdver=2&bc=AgAAQAAAAAAA&. Accessed November 8, 2022. 

Chao TF, Lin YJ, Tsao HM, et al. CHADS(2) and CHA(2)DS(2)-VASc scores in the prediction of clinical outcomes in patients with atrial fibrillation after catheter ablation. J Am Coll Cardiol. 2011;58(23):2380-5.

Christensen LM, Krieger DW, Hojberg S, et al. Paroxysmal atrial fibrillation occurs often in cryptogenic ischaemic stroke. Final results from the SURPRISE study. Eur J Neurol. 2014;21(6):884-9.

Ciconte G, Saviano M, Giannelli L, et al. Atrial fibrillation detection using a novel three-vector cardiac implantable monitor: the atrial fibrillation detect study. Europace. 2017;19(7):1101-8.

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Cotter PE, Martin PJ, Ring L, et al. Incidence of atrial fibrillation detected by implantable loop recorders in unexplained stroke. Neurology. 2013;80(17):1546-50.

Crawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA Guidelines for Ambulatory Electrocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Developed in collaboration with the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol.1999;34(3):912-48.

Culebras A, Messe SR, Chaturvedi S, et al. Summary of evidence-based guideline update: prevention of stroke in nonvalvular atrial fibrillation: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014;82(8):716-24.

Da Costa A, Defaye P, Romeyer-Bouchard C, et al. Clinical impact of the implantable loop recorder in patients with isolated syncope, bundle branch block and negative workup: a randomized multicentre prospective study. Arch Cardiovasc Dis. 2013;106(3):146-54.

Dagres N, Kottkamp H, Piorkowski C, et al. Influence of the duration of Holter monitoring on the detection of arrhythmia recurrences after catheter ablation of atrial fibrillation: implications for patient follow-up. Int J Cardiol. 2010;139(3):305-6.

Davidson KW, Barry MJ, Mangione CM, et al. Screening for Atrial Fibrillation: US Preventive Services Task Force Recommendation Statement. JAMA. 2022; 327(4):360-7. ​

Derkac WM, Finkelmeier JR, Horgan DJ, et al. Diagnostic yield of asymptomatic arrhythmias detected by mobile cardiac outpatient telemetry and autotrigger looping event cardiac monitors. J Cardiovasc Electrophysiol. 2017;28(12):1475-8.

DiMarco JP, Philbrick JT. Use of ambulatory electrocardiographic (Holter) monitoring. Ann Intern Med. 1990;113(1):53-68. 

Dorr M, Nohturfft V, Brasier N, et al. The WATCH AF Trial: SmartWATCHes for Detection of Atrial Fibrillation. JACC Clin Electrophysiol. 2019; 5(2):199-208.


Ermis C, Zhu AX, Pham S, et al. Comparison of automatic and patient-activated arrhythmia recordings by implantable loop recorders in the evaluation of syncope. Am J Cardiol. 2003;92(7):815-9.

Etgen T, Hochreiter M, Mundel M, et al. Insertable cardiac event recorder in detection of atrial fibrillation after cryptogenic stroke: an audit report. Stroke. 2013;44(7):2007-9.

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Eysenck W, Freemantle N, Sulke N. A randomized trial evaluating the accuracy of AF detection by four external ambulatory ECG monitors compared to permanent pacemaker AF detection. J Interv Card Electrophysiol. 2020;57(3):361-9.​

Farris GR, Smith BG, Oates ET, et al. New atrial fibrillation diagnosed by 30-day rhythm monitoring. Am Heart J. 2019;209:29-35.

Fitzmaurice DA, Hobbs FD, Jowett S, et al. Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial. BMJ. 2007;335(7616):383.

Gersh BJ, Bonow RO, Fifer MA, et al. 2011 American College of Cardiology Foundation/American Heart Association guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(24):2761-96.

Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370(26):2467-77.

Gladstone DJ, Wachter R, Schmalstieg-Bahr K, et al. Screening for Atrial Fibrillation in the Older Population: A Randomized Clinical Trial. JAMA Cardiol. 2021;6(5):558-67.
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Halcox JPJ, Wareham K, Cardew A, et al. Assessment of remote heart rhythm sampling using the AliveCor Heart Monitor to screen for atrial F\fibrillation: The REHEARSE-AF Study. Circulation. 2017;136(19):1784-94.

Hanke T, Charitos EI, Stierle U, et al. Twenty-four-hour holter monitor follow-up does not provide accurate heart rhythm status after surgical atrial fibrillation ablation therapy: up to 12 months experience with a novel permanently implantable heart rhythm monitor device. Circulation. 2009;120(11 Suppl):S177-184.

Higgins P, MacFarlane PW, Dawson J, et al. Noninvasive cardiac event monitoring to detect atrial fibrillation after ischemic stroke: a randomized, controlled trial. Stroke. 2013;44(9):2525-31.

Hindricks G, Pokushalov E, Urban L, et al. Performance of a new leadless implantable cardiac monitor in detecting and quantifying atrial fibrillation: Results of the XPECT trial. Circ Arrhythm Electrophysiol. 2010;3(2):141-7.

Hoefman E, Bindels PJ, van Weert HC. Efficacy of diagnostic tools for detecting cardiac arrhythmias: systematic literature search. Neth Heart J. 2010;18(11):543-51.

January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):2246-80.

January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2019;16(8):e66-e93.
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Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography. A report of the ACC/AHA/ACP-ASIM Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography). J Am Coll Cardiol. 2001;38(7):2091-100. ​

Kadish AH, Reiffel JA, Clauser J, et al. Frequency of serious arrhythmias detected with ambulatory cardiac telemetry. Am J Cardiol. 2010;105(9):1313-16.

Kalani R, Bernstein R, Passman R, et al. Low yield of mobile cardiac outpatient telemetry after cryptogenic stroke in patients with extensive cardiac imaging. J Stroke Cerebrovasc Dis. 2015;24(9):2069-73.

Kapa S, Epstein AE, Callans DJ, et al. Assessing arrhythmia burden after catheter ablation of atrial fibrillation using an implantable loop recorder: the ABACUS study. J Cardiovasc Electrophysiol. 2013;24(8):875-81.

Kaura A, Sztriha L, Chan FK, et al. Early prolonged ambulatory cardiac monitoring in stroke (EPACS): an open-label randomised controlled trial. Eur J Med Res. 2019;24(1):25. 

Kishore A, Vail A, Majid A, et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke. 2014;45(2):520-6.

Lazzaro MA, Krishnan K, Prabhakaran S. Detection of atrial fibrillation with concurrent holter monitoring and continuous cardiac telemetry following ischemic stroke and transient ischemic attack. J Stroke Cerebrovasc Dis. 2012;21(2):89-93.

Leshem-Rubinow E, Berger M, Shacham J, et al. New real-time loop recorder diagnosis of symptomatic arrhythmia via telemedicine. Clin Cardiol. 2011;34(7):420-425.

Lobodzinski SS. ECG patch monitors for assessment of cardiac rhythm abnormalities. Prog Cardiovasc Dis. 2013;56(2):224-9.

Locati ET, Vecchi AM, Vargiu S, et al. Role of extended external loop recorders for the diagnosis of unexplained syncope, pre-syncope, and sustained palpitations. Europace. 2014;16(6):914-22.

Mayo Clinic. Hypertrophic cardiomyopathy. [Mayo Clinic We site]. 04/18/2018. Available at:
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Miller DJ, Khan MA, Schultz LR, et al. Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke. J Neurol Sci. 2013;324(1-2):57-61.

Mittal S, Movsowitz C, Steinberg JS. Ambulatory External Electrographic Monitoring: focus on atrial fibrillation. J Am Coll Cardiol. 2011;58(17):1741-9.

Morey SS. ACC/AHA guidelines for ambulatory ECG. Am Fam Physician. 2000;61(3):884-8.

Mullis AH, Ayoub K, Shah J, et al. Fluctuations in premature ventricular contraction burden can affect medical assessment and management. Heart Rhythm. 2019;16(10):1570-4. 


Narasimha D, Hanna N, Beck H, et al. Validation of a smartphone-based event recorder for arrhythmia detection. Pacing Clin Electrophysiol. 20189;41(5):487-94.

Ng E, Stafford PJ, Ng GA. Arrhythmia detection by patient and auto-activation in implantable loop recorders. J Interv Card Electrophysiol. 2004;10(2):147-52.

Nolker G, Mayer J, Boldt LH, et al. Performance of an Implantable Cardiac Monitor to Detect Atrial Fibrillation: Results of the DETECT AF Study. J Cardiovasc Electrophysiol. 2016;27(12):1403-10.

Novitas Solutions, Inc. Local Coverage Determination (LCD).L34953. Cardiac event detection monitoring. [Novitas Solutions, Inc. Web site]. 10/01/2015. Revised 10/17/2019. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34953&ver=27&Keyword=Cardiac+event+detection+monitoring&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC|SAD|RTC|Reg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed November 8, 2022. 

Novitas Solutions, Inc. Local Coverage Determination (LCD)(L34997) .Real-Time, Outpatient Cardiac Telemetry. [Novitas Solutions, Inc. Web site]. 10/01/2015. Revised 10/17/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34997&ver=18&articleId=57434&name=331*1&UpdatePeriod=855&bc=AAAAEAAAAAAA&. Accessed November 8, 2022. 

Novitas Solutions. Inc.  Local Coverage Article (LCA): Billing and Coding: Real-Time, Outpatient Cardiac Telemetry (A52995). Original Effective Date: 10/01/2105. Revision Effective Date: 10/01/2019. [CMS Website]. Available at:  

Novitas Solutions. Inc.  Local Coverage Article (LCA): Cardiac Event Detection Monitoring (A56600). Original Effective Date: 06/13/2019. Revision Effective Date: 10/01/2022. [CMS Website]. Available at:  

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Coding

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

0650T, 33285, 33286, 93224, 93225, 93226, 93227, 93228, 93229, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272, 93285, 93291, 93298
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
G45.1Carotid artery syndrome (hemispheric)
G45.2Multiple and bilateral precerebral artery syndromes
G45.8Other transient cerebral ischemic attacks and related syndromes
G45.9Transient cerebral ischemic attack, unspecified
G46.0Middle cerebral artery syndrome
G46.1Anterior cerebral artery syndrome
G46.2Posterior cerebral artery syndrome
G90.APostural orthostatic tachycardia syndrome [POTS]
I25.82 Chronic total occlusion of coronary artery
I42.0Dilated cardiomyopathy
I42.1Obstructive hypertrophic cardiomyopathy
I44.0Atrioventricular block, first degree
I44.1Atrioventricular block, second degree
I44.2Atrioventricular block, complete
I44.30Unspecified atrioventricular block
I44.39Other atrioventricular block
I44.4Left anterior fascicular block
I44.5Left posterior fascicular block
I44.60Unspecified fascicular block
I44.69Other fascicular block
I44.7Left bundle-branch block, unspecified
I45.0Right fascicular block
I45.10Unspecified right bundle-branch block
I45.19Other right bundle-branch block
I45.2Bifascicular block
I45.3Trifascicular block
I45.4Nonspecific intraventricular block
I45.5Other specified heart block
I45.6Pre-excitation syndrome
I45.81 Long QT syndrome
I46.2Cardiac arrest due to underlying cardiac condition
I46.8Cardiac arrest due to other underlying condition
I46.9Cardiac arrest, cause unspecified
I45.89 Other specified conduction disorders
I45.9Conduction disorder, unspecified
I47.0Re-entry ventricular arrhythmia
I47.1Supraventricular tachycardia
I47.20Ventricular tachycardia, unspecified
I47.21Torsades de pointes
I47.29Other ventricular tachycardia
I47.9Paroxysmal tachycardia, unspecified
I48.0Paroxysmal atrial fibrillation
I48.11Longstanding persistent atrial fibrillation
I48.19Other persistent atrial fibrillation
I48.20Chronic atrial fibrillation, unspecified
I48.21Permanent atrial fibrillation
I48.3Typical atrial flutter
I48.4Atypical atrial flutter
I48.91Unspecified atrial fibrillation
I48.92Unspecified atrial flutter
I49.01Ventricular fibrillation
I49.02Ventricular flutter
I49.1Atrial premature depolarization
I49.2Junctional premature depolarization
I49.3Ventricular premature depolarization
I49.40Unspecified premature depolarization
I49.49Other premature depolarization
I49.5Sick sinus syndrome
I49.8Other specified cardiac arrhythmias
I49.9Cardiac arrhythmia, unspecified
I63.541Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery
I63.542Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery
I63.549Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery
I63.59Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
I63.89Other cerebral infarction
I63.9 Cerebral infarction, unspecified
I67.841Reversible cerebrovascular vasoconstriction syndrome
I67.848Other cerebrovascular vasospasm and vasoconstriction​
Q24.6 Congenital heart block
R00.0Tachycardia, unspecified
R00.1Bradycardia, unspecified
R00.2Palpitations
R06.00Dyspnea, unspecified
R06.02Shortness of breath
R06.09 Other forms of dyspnea
R06.3 Periodic breathing
R07.89 Other chest pain
R07.9 Chest pain, unspecified
R42Dizziness and giddiness
R55Syncope and collapse
Z09Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z86.74 Personal history of sudden cardiac arrest


TO INDICATE THE MEDICAL NECESSITY OF MONITORING DUE TO AN ABNORMAL ECG/EKG, MULTIPLE DIAGNOSIS CODES ARE REQUIRED:

PRIMARY
R94.31 Abnormal electrocardiogram [ECG] [EKG]

SECONDARY
R06.00Dyspnea, unspecified
R06.02Shortness of breath
R07.89 Other chest pain
R07.9 Chest pain, unspecified
R42Dizziness and giddiness
R55Syncope and collapse

TO INDICATE THE MEDICAL NECESSITY OF MONITORING FOR ANTICOAGULATION THERAPY DISCONTINUATION, MULTIPLE DIAGNOSIS CODES ARE REQUIRED:

PRIMARY
Z79.01 Long term (current) use of anticoagulants

SECONDARY
I48.0 Paroxysmal atrial fibrillation
I48.20Chronic atrial fibrillation, unspecified
I48.21Permanent atrial fibrillation
I48.91
Unspecified atrial fibrillation

HCPCS Level II Code Number(s)

C1764 Event recorder, cardiac (implantable)
C1833
Monitor, cardiac, including intracardiac lead and all system components (implantable)​
E0616
Implantable cardiac event recorder with memory, activator, and programmer
G2066 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results​


Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

1/1/2023
12/30/2022
07.02.21
Medical Policy Bulletin
Commercial
No