Hi, everyone. My name is Nicole Knight. I'm the Executive Vice President of Revenue Cycle Solutions and Care Transformation with Medaxium. And I'm joined by CB Remote Solutions in presenting the device clinic essentials for the care team. This module will focus on coding, billing, and documentation for our CIED monitoring. Our objectives for this module is to talk about the professional service coding and billing for our implantable electronic device monitoring, to discuss reimbursement principles related to the billing, and the documentation best practices. When we talk about CIED management services, that ongoing monitoring and patient care is the standard of care. They have to be regularly interrogated and reprogrammed to ensure proper functioning. This may also include programming. Remote monitoring allows for interrogation at a remote location. Even our interrogations can now be done on our ILR monitors and now have programming of those devices. So looking at in-person versus remote, and the billing and coding requirements related to those services. Medicare and non-Medicare carriers provide the coding and billing frequency guidelines for these services. So we'll cover that as well as we talk about the different types of devices. So the types of devices. So for our pacemakers, our defibrillators, or ICDs is how we always have the alphabet soup when you're looking at these. Our CRT devices, which is our cardiac resynchronization therapy, or our CRTDD, or CRTP, those are for those resynchronization therapies based on if it's a defibrillator or a pacemaker. And then our subcutaneous monitors, which are implantable loop recorders, or our ICMs, which are those physiologic monitoring devices that provide that physiological data, mostly around our congestive heart failure patient. So what are some of the billing considerations in the management of our implantable devices? So when you look at order requirements, CID management services are considered diagnostic testing services. So diagnostic testing services must be ordered by a provider who's treating the patient, who uses the results to treat that patient and record the patient's information in their medical record. Orders can be written, a telephone or verbal order, as we refer to, or an electronic order. And of course, Medicare does have guidelines around the types of orders and what the requirements that must be met for if it's written, verbal, or electronic. Also, for our device clinics, we often see standing orders that are renewed annually based on the cadence of their remote devices versus their in-person interrogation. So you want to be sure if you're using a standard order what that process is for ensuring that that meets the Medicare requirements for the order of the diagnostic test. Again, you have to ensure that you do have an order for that, even though it's occurring on an ongoing basis. So what are some of the reimbursement considerations? Well, you have to have documentation to support the medical necessity, of course, of that service. If there's authorization requirements that are needed, is there a diagnostic test separately billable during the global period? What are the coverage timelines? So is it a 30-day interval, a 90-day interval based on the device? And then CMS, our Medicare and Medicaid services, has national coverage determinations. And also, depending on your state and region, may have a local coverage determination. So you want to be sure that you're pulling that. It will have the information needed for medical necessity, for timelines that are supportive of Medicare or your local Medicare carrier. When we talk about diagnostic testing services, supervision is assigned to each individual CPT code that we use for billing. So depending on the CPT code you're billing, you can go to the Medicare Physician Fee Schedule, and they're assigned a supervision code, either 01, 02, 03, et cetera. So when we talk about devices, we're going to focus on general supervision, which means that the procedure is furnished under the overall direction or control of a physician's present, but not required during the performance of the procedure, and then direct supervision, meaning the provider is present in an office suite, immediately available to furnish and direct the performance of that procedure. It does not mean that they have to be in the room when the procedure is performed, but they do have to be present within an office suite. So we'll talk a little bit about the variation of direct versus general supervision, but those are the most applicable when we talk about our implantable device monitoring. So for professional service billing, so this is based on the Medicare Physician Fee Schedule and our global professional billing, you have to know the place of service that you're providing the service for the device check. This refers to when you're looking at global, you're billing both components of the service. So you're billing a single charge that covers all aspects of that patient's care that's related to the specific service or procedure. It offers a bundled payment that covers that entire scope of care, and that's the professional and technical, and you bill globally if one entity is responsible for providing both the technical and professional. So when you think about billing globally, you have to think about what's required of the technical, what's required of the professional, am I meeting the definition of all aspects of that in order to bill based on a single charge that covers both the professional and technical service? For a professional component or PC, this is often identified by modifier 26 after the CPT code and represents the physician's work of interpreting the diagnostic test or performing the procedure. It includes some indirect practice and malpractices expenses related to that work. The date of service for the professional component is the date the physician completes the study if not billing global. So what does that mean? So if you're not billing global and you're billing the CPT code with the 26 to indicate the professional component, then that service for that professional component is to be billed on the date that the physician does the interpretation. So it goes back to place of service, date of service, and what service are you providing? Is it just the professional service? Is it the technical service? Is it the global service? So for the technical component, that's the non-physician work. So this is the capital equipment, facility costs, administrative personnel. When you look at a technical component, we have the TC modifier that indicates that. When we talked about the industry rep-supported clinics that we occasionally see, the TC is generally not billed. That technical component is not billed by the practice. The practice is billing that professional component and using the 26, so that would be an example. When you look at the service for both the technical, the professional, and the global code, it's assigned that supervision requirements. So when you look at in-person management, it has a direct supervision requirement on the technical piece, meaning that the practitioner must be present in the office seat or hospital setting and immediately available based on the billing place of service. So again, when you look at what's direct, what's general, you want to be sure that you're relating that to the place of service you're billing, whether it's an office clinic, place of service 11, a hospital-based clinic, which could be a place of service 22. Am I billing the technical only, the professional only, or am I billing global? When you look at remote monitoring, it has general supervision, meaning, of course, it's under the overall direction of a provider. Also, it's important when we look at the definition of those supervision codes, as we gave an example of 01 to 02, effective in 21, Medicare permitted non-physician practitioners, such as advanced practitioner, nurse practitioners, physician assistants, that are able to bill for their Medicare services, that they can supervise diagnostic testing. This is based on their state scope of licensure, so you have to be sure you're in compliance with that, but when we talk about physician supervision now, the definition says physician, but it is still relevant that our advanced practitioners may supervise diagnostic tests to meet either the general direct supervision. So we mentioned place of service, what is this? This is a two-digit code where the healthcare professional service took place, and it indicates on the claim form where that service was provided. It's used throughout the healthcare industry, so it's not just for office or outpatient clinic. It's inpatient hospital, it's home, it's ambulatory surgery center. There's a defined list of place of service codes. This is some common place of service codes. This is not an all-inclusive list, but similar to what I told you, there are variable ones. It's a long list. I will tell you the most common for our device clinic services are 11, place of service 11 for office, place of service 22 if you have an outpatient hospital clinic device clinic. So those are some common ones. Again, this is not an all-inclusive list, but that place of service would refer to the location of where the service was provided, and there are rules on if you're billing globally, if you're billing just the professional or the technical service. So you want to be sure you're in alignment with that. Code assignment and reimbursement. So let's talk about those CPT codes that are billed and how they're reimbursed for CIED management. So for our interrogations, this is an evaluation of the device. It's the stored details of that device being retrieved, and that retrieved information is evaluated to determine the current programming of the device. So we often refer to this as a data download, meaning I'm interacting with the device and downloading the data, but I'm not necessarily making any changes. I'm just really downloading that stored information for review. So what are some components of an in-person interrogation? So these are our different devices. So for example, when you look at our pacemaker and ICDs, you're going to get some of those programmed parameters of where the device was programmed, the leads, the battery, the capture and the sensing function. Then you're going to see for your pacemakers, is there presenting heart rhythm? On your ICDs, is there a presence or absence of therapy for all arrhythmias? So is there something that's showing from a rhythm arrhythmia standpoint? For your ICM devices, this is that physiological data. So you're getting an analysis of what was recorded from that physiological device, whether it's either internal or external sensors. And for our ILRs, our subcube loop monitors, you're getting those program parameters of that device, the heart rhythm during the recorded episode, and this can be both patient initiated or it can also be an algorithm of detected events when present. So you're getting some information that is stored within that device, and you're downloading that interrogation data for review interpretation by a provider. For the in-person interrogation, we do have CPT codes for that. You have to remember for interrogation services, they are allowed, patients are allowed for our pacemaker ICD monitors, as an example, to have an interrogation every 90 days. So it's important whether they're having in-person or remote, which one am I billing and are we meeting the timeline? So when you look at these codes, the in-person interrogation only, this is downloading the information from the device that's been stored. So when you talk about interrogation procedures and reporting the CPT code, it's reported per procedure. It may not be reported with programming on the same day to service. So we're gonna go over what those programming codes are, and it may not be reported with remote interrogation. So again, every 90 days, as an example, for our loop recorders, it's 30 days. So again, it's important to know what are the requirements for interrogation timelines and for in-person and for remote services, and how do those overlap in my clinic. For programming evaluations, this is truly interacting with the device. So there's significantly more work than interrogation. I'm not just downloading the parameters. These are billable within the remote interrogation timeframe. So if I'm getting remote interrogations and I come to the office for programming, that programming is separately billable. The code's chosen based on the number of leads or chambers. With each lead check, there is more work involved in that programming. It's important to remember that programming does not mean that I am changing the programming of the device. It means that I am interacting with the device and the parameters of that device. So this is an example of some of the components that we'll see. The most common one, I'll tell you, we see threshold testing. We see other requirements that are happening with that programming to get sensing and different aspects based on the type of device that it is. Also, if I'm interacting with the device, it does not mean that I have to change the programming in order to build this. So programming definition of the CPT code supports interacting with the device and evaluating the parameters of that device, not just interrogating and downloading the data. So these are our codes for in-person programming, which again are based on the device and are also based on the leads for our pacemaker and defibrillators and can be billed within the interrogation timeframe for remote or in-person interrogation. So programming is billable if supported in the documentation as programming. And it's important to note, because we have seen this be a challenge where you may not always be capturing your programming. So it's important to know the definition of programming, which is interacting with the device and what that means during that interrogation period as it is billable. So we talked about for in-person, you're gonna bill according to the number of leads or chambers based on your pacemaker and ICD devices. It is billable within the remote or telephone service period. Telephone service, there are still telephone service-based codes. These are for older devices. We don't see them nearly as much, but there are a few still out there. Programming can only be done in person for pacemaker and defibrillators. However, for our loop recorders, there is a programming for remote, so important to remember that. But pacemakers and ICDs, which have leads and chambers, those are only done in person. There's no service period. So for your programming, there's no service period requirement. It does not require that a setting be reprogrammed, and the device techs and providers must document the distinction between these. So you want to be sure your documentation supports when it's an interrogation and when it's a programming evaluation. So to recap on interrogation versus programming, you're interacting with the device for programming. You're not just downloading the data. You may be making adjustments, but it is not required. But you again may be making some to find the most appropriate setting. You may decide to leave them the same, and this would still be billed as a programming evaluation. This is the CPT guidance on interrogation versus programming. Often, but not always, for programming, you will see these elements that are circled during a programming evaluation. And again, we emphasize that the parameters may or may not be changed after evaluation. But this just gives you an idea of what you're looking for in the report. However, we know that device checks, whether it's an interrogation or a programming, require an interpretation. So you're going to see these parameters, but you also have to have an interpretation. And we do advise providers to designate if they're doing an interrogation versus a programming so that we know we're capturing the correct time frame required for interrogation and that we're able to capture all of the programming that's being performed. For our periprocedural device services, these are services that are for our pacemakers and ICDs that are done before or after surgery, procedure, or test. So they'll turn the device off before a procedure or test and turn it back on after. So we do have codes to support that based on if it's a pacemaker or an ICD. And these are billable services. And often, we see some of our device clinic teams being a part of this. At times, we see these billed by physicians only because these patients may be in the hospital. We see advanced practitioner programs where they're providing this service, but this is truly turning that device on and off before or after a procedure. So when we look at the 24 coding and reimbursement for in-person pacemaker, this is the Medicare physician fee schedule. So we've broken these out and provided these charts to supply you with what is the CPT code, what is the description of that CPT code, whether it's programming or interrogation, if it's peri-procedural, and you can see that telephone strip for our pacemaker there. It includes the work RBUs, the national global payment, the professional service payment, and the technical payment based on the national Medicare physician fee schedule. Your local Medicare carrier may vary, but as you can see with our pacemaker in-person services, it's based on the number of leads. If you're doing programming, interrogation, peri-procedural, or that trans-telephonic. And then for ICD in-person, same type of chart. You'll see it looks the same as our pacemaker. It's programming based on the number of leads, interrogation, and peri-procedural. There's no trans-telephonic for ICDs, but these are the CPT codes and the work RVUs and reimbursement. This is our physiological monitors, our ICMs and our ILRs. So this is the interrogation and programming of those devices as well. So you can see the bolded ones. You want to be sure I'm number one, the description, and I'm meeting the description. Is it interrogation? Is it programming? The type of device? If it requires the number of leads, you want to be sure that you're identifying the correct code. When we talk about remote monitoring, so we covered in-person, what it means around interrogation and programming. So when we talk about remote monitoring, this is device information that's sent automatically or transmitted to the provider. The patient's not physically at the facility. It travels from the remote monitor to the clinic and the clinic reviews that device information, generally via a secure website. Sometimes different vendors of devices have different websites and platforms. That information can be downloaded into a central system that you may be using that's supported, but normally this is coming from a secure device website. When you look at remote monitoring, the same when you look at professional versus technical component. There's a professional for our device based on the device, and then there's a professional component. So these codes are different than our in-person and they have different timelines based on that remote monitoring interrogation. So we talked about our pacemaker and ICDs have an interrogation period of 90 days. Our loop monitors or ICMs have that 30-day monitoring, so it's important to know that time frame for that interrogation. And of mention, we included the extravascular substernal ICD codes on here. They are temporary codes. They are new and these devices are implantable in a sense of it's tunneled under the skin and placed substernally as opposed to the placement of our permanent transvenous ICDs. It also is a T-code, which means it's a temporary code, so doesn't have a CPT code yet. Therefore, the carrier reimbursement varies based on your region and state. I have not seen a lot of these devices yet, but we wanted to include them because, again, this is an ever-changing world in healthcare as well with device technology. So forever, we had pacemakers, ICDs, then we had loops, then we had ICMs, and then we have many other devices, and wanted to just mention those as we will start to see those devices. And normally, it takes about two to three years to get a CPT code that relates to those devices, but this is the temporary codes for those. So remote interrogation of our pacemaker and ICDs. So an interrogation is an interrogation, whether it's in-person or remote. Once a remote interrogation has been billed in a 90-day period for our pacemakers and ICDs, that's including in-person or remote. They are not separately billable. You cannot report if the monitoring period is less than 30 days. So if you do a remote monitoring less than 30 days, it's not billable. The 90-day service period applies to interrogation services only, and programming is separately billable during that interrogation period for our pacemaker and ICD devices. For our ILR, our loop subcutaneous monitors, it's not billable with a minimum of 10 days of monitoring. So each of these CPT codes have a minimum and a allowable billable threshold. So for the remote interrogation, these are billable once every 30 days. So an in-person interrogation is not billable during the remote period. In-person programming is separately billable in the 30-day period. So remember we have this programming remote service code, and that is separately billable, just like programming for our other devices is separately billable. So interrogation, whether it's office or remote, billable once every 30 days for our ILR loop subcutaneous monitors. Our ICMs, this is our physiological data. The service period is 30 days, not 90 days. Why is that important, and why do we emphasize that on our ICMs? Oftentimes our patients may have a device that has multiple capabilities. So they may have an ICD that is also an ICM. So that ICD monitoring period is 90 days, but the ICM service period is 30 days. So important to know your device and what services that it provides to that patient. It does have a minimum of 10-day monitoring, and it will most likely be used to manage the congestive heart failure of a patient. So for ICM services, it's interesting because it's been hard to manage the data from these devices, because as we mentioned, oftentimes we're doing our ICD or our pacemaker services, and they may have an ICM component. That ICM component may not be managed by the electrophysiologist in an example. It may be managed by the heart failure team. So how is that information delivered, communicated to the heart failure team, to the patient? You're looking at two different time frames. How are you managing that? So important to know how that's being managed, and if you are capturing the interpretation of those services in the time frame and billing for that service. So when we look at remote monitoring, these are our interrogation services for our ILRs, our pacemaker defibrillators. So these are all the codes. You can see where there's a global billing component, and then there's a technical billing component, depending on the device that you're using, and the code may represent professional service only, or may represent national global only. You want to be sure that you're meeting the components of the code. So what does that mean? So if you look at 93296, it has a global payment of $20.96. This is global because it only supports the technical support of the device and the distribution of the results for the pacemaker or defibrillator system. So this is our technical portion. If you look at the 9-4 or the 9-5, this is the professional service of our pacemaker and ICD. So depending on if you're providing the professional and technical will depend on how you bill for that. Now when you look at our ICM and ILR monitoring, they have a global professional and technical on the same code. So again, you have to determine which services you're providing, if you're providing the professional and the technical, or if you're providing the professional only or the technical only, and bill accordingly. So this for our ICM and ILRs, this code in CPT was changed to have both a technical and professional component recently. It used to have a separate code for Medicare, which was a G code. However, now that is built into the CPT code, so it's important to know whether you should be billing globally, professionally, or technically. Documentation. Let's talk about what's required in documentation. So we talked about medical necessity. So this is supporting that patient's condition, particularly if you're doing interrogations, all of those things of the patient coming into the office, if they're having clinical symptoms, their device is into life, you want to be sure you're supporting that medical necessity. You want to document the monitored data that was recorded and reviewed by the qualified healthcare professional, which is in from a CMS Medicare perspective, an advanced practitioner or a physician. You want to document your patient engagement. So did you notify the patient? Were there any interventions on the monitored data? So if any of that applies, you want to be sure to document that, and you have to have an interpretation. A report including the findings, relevant clinical issues, it should clearly indicate that the provider personally reviewed the results and provided the interpretation. So many of our systems give us the reason for the device check, they give us the patient information, and they give us the data, what was the monitoring of the data. Then the physician has to provide a interpretation of that data. So it's important, it doesn't have to be a complete separate report, but it does have to include an interpretation that was personally performed or reviewed by the physician or advanced practitioner, and it has to be documented and signed as well. So tips to answer if you've met medical necessity, what service is needed, why are you performing it, and does the reason for the service meet the national and local coverage guidelines? This comes into play in our device clinics, mainly around the timeline of interrogation services. So you want to be sure you're meeting those coverage guidelines as a reason as to why you're performing the service, and if the service is needed. How, who, and where will the service be provided? So again, what's my place of service? What provider is interpreting that service? And how is it being performed? And what is being performed? Is it an interrogation? Is it programming? Is it a physician? Is it an APP? Is it in clinic? Is it remote? What does that service and what is being provided? Do I have an order and documentation to support the service? So you want to be sure you're checking the boxes on all of those to meet that medical necessity component. Some key considerations around charge capture and documentation storage. So it's one thing to capture and bill for your services. You want to be sure that you have access to the documentation to support the charges that were billed on the claim. So missing charges can lead to revenue loss. So you want to establish a process to know all of the patients that we saw for a programming today were billed. Those charges were captured, billed, and documented. Same with remote monitoring. You want to be sure that you have processes in place to reconcile those services and capture charges. You want to do a regular audit on the coding and documentation accuracy. So am I coding appropriately for interrogations, timelines? Am I coding and billing for programming? Is the documentation of the interpretation being done and signed by the provider? You want to leverage your technology to automate and integrate any documentation and charge capture because this helps if you're using manual processes and paper, there's always something missed. You have to be sure you have access to everything, the data and the interpretation. Do you have access to that? If a payer asks for that information, are you able to send them the downloaded device data and the interpretation to support that service build if you're billing for both of those? Ensure effective communication and collaboration between the clinical team, providers, and billing. This is back to what is the timeliness of my interpretations, the timeliness of billing and capturing charges, and the timeliness of reconciliation. So this ensures that financial stability of your clinic and of course the sustainability of your clinic for growth and supportive resources and staffing. We provided some references that has both the CPT information from the American Medical Association, also some of the manual information around the claims processing manual and the physician fee schedule as a reference to coding and billing. We hope you enjoyed this module and we look forward to seeing you on additional modules. Thank you.

CIED monitoring

reimbursement principles

documentation best practices

pacemakers

defibrillators

remote monitoring

medical necessity