Alright, well, we'll go ahead and get started. I see people are still dialing in, but we'll do the housekeeping slides and all that first. So I'll start with introductions. So good afternoon, everybody. And thank you for joining us today. This is our third series of our EP series that we're giving this year. My name is Jamie Quimby, and I'm the Director of Coding with our Revenue Cycle Solutions Department with MedAxiom. Today, I'm going to cover EP diagnostic arrhythmia and device monitoring services. If you missed the first two series that were presented this year, you can find both of the recorded presentations in our MedAxiom Academy platform. And we did offer those, both of those, along with this one are being offered as on demand. So if you did not attend the live session, you do have the option to take a quiz at the end of the recorded session and obtain your CEU certificate still. Today's webcast, like I said, will also be offered in the on demand platform. If you attend the live session, you do not have to take the quiz, you'll still get your CEU certificate. Again, I do plan to do an advanced EP session later this year during our boot camp series. We give that in December. That presentation will heavily focus on coding real cases that are more complex to the specialty. So stay tuned for that registration details once we start posting the details of the December boot camp. All right, so to access the slides for the presentation, you need to click on the chat box, and there will be a link in there for you to click on. Please do not use that chat box for anything else, especially questions. There is a separate questions box to click on if you do have a question related to our topic today. Again, we do ask that you keep your questions on topic. We will answer questions at the end, but we do compile our questions that we get in the Q&A box, and we do post that Q&A document on our MedAxium platform site. So you will be able to find that document later as well. So with our MedAxium Academy platform, a lot of you that attend our webcast are familiar with how the process goes now, but we do now upload your CEU certificate directly to your account. Please give us one to two business days to allow our team time to get that certificate uploaded. Your name is automatically added to the certificate. It's super easy to download. Once you download it, you can drag it to your desktop. It's easy to upload as you're claiming your CEUs, whether you're with AAPC. AHIMA does currently accept AAPC certificates. If you have an AHIMA credential right now, you do know that they're changing some of their policies with their CEUs, I think starts next year. I think about 40% of them will have to come directly from them, but you still will be able to claim some of your other CEUs, you know, from AAPC as well. All right, so this is just a screenshot of how you would download your certificate if you're not familiar. You would log into your account. You would go to your transcript of where, you know, of your MyAcademy, and then you would click on that topic, and then there's an option for you to click download. All right, so our objectives today are to cover some key insights for diagnostic arrhythmia testing guidelines. We'll go over the CMS supervision requirements. We'll also talk about coding, documentation, and reimbursement. So as coders, we know obviously documentation is key. If it's not documented, it didn't happen. That's one of our favorite quotes we say. So again, clear, consistent, complete, precise, timely, and legible documentation should accurately reflect the patient's condition and the management. With that documentation, that patient's clinical status should be seen, and that would then translate into that coded data that we would be doing. The coded data then would translate into quality reporting, physician report cards, public health data, disease tracking, and again, reimbursement. In addition, the clinical documentation does have a direct impact on that patient's care as it provides information to the care team as well as other clinicians that may be treating that patient. So with medical necessity guidelines, you know, how does that look from a payer perspective? So first, there must be documentation, obviously, to support the intent to order the service and why it's being requested. This is going to be your diagnosis or the reason for the request. Then you'll want to check if National Medicare has any national coverage determinations. We typically just call it NCDs, see if they have a policy, or if your local Medicare contractor may have a local coverage determination policy, which again, we typically will call an LCD. Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Again, National Medicare is going to, if they need to, they'll create that national coverage determination. In the absence of a national coverage determination policy, they do leave it at the discretion of the Medicare contractors and whether or not they're going to create a local coverage determination. Sometimes you may see both. Sometimes there's going to be a national coverage determination and then that specific Medicare contractor may also create a local coverage determination. You will also want to check with any other payers that you may deal with. Sometimes a lot of the commercial payers will also list their own policies with their coverage and regulations. So you'll want to just stay up to date on that. And then finally, you'll want to check with that patient's insurance plan to see if there's any authorization requirements that may be needed since, again, we are talking about diagnostic services today. So this is guidance from Medicare on order requirements from a benefit policy manual perspective. Again, Medicare defines this as an order is a communication from the treating physician or practitioner requesting that a diagnostic service be performed for a beneficiary. Typically, there will be a written document from the provider's office stating what services are being ordered or requested, along with the indications for that study. This can be placed in an electronic format, a hand-delivered, mailed, or faxed to the testing facility. There are times, though, when a verbal order may be given. Typically, when that happens, the nurse that's taking the verbal order or, you know, whoever the provider could be, they will usually put that order into their system. So there will still be a tracking for that. So signature requirements. All medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating that service. There's questions a lot with certain things. EKGs is one that we see a lot, especially if you're, if you own your equipment and you're doing your EKGs, like in your office setting. If your provider does not document, because they're billing for that professional interpretation. So whether or not they agree with the reading of the EKG strip itself and are going off of that, or if they're documenting their personal interpretation with this, within, you know, an office note that same day being provided, there has to be a signature for that interpretation. So if they're not adding it within their E&M note itself, and they're simply going by the EKG strip, sometimes they handwrite their interpretation on that strip. There still has to be a signature in that case. So, you know, that is a requirement from Medicare. All right. So when looking at the professional and technical aspects of our diagnostic services, sometimes modifier 26 or modifier TC may be applicable for that particular service. So again, when you're looking at the differences between the two, for the professional component, these items represent the physician's work or the professional component. So that would include your, you know, interpretation of that study. You know, it's going to include malpractice expenses that are related to that work. It's going to have a work RVU assignment from a, you know, reimbursement perspective from Medicare. And then, of course, if the modifier is applicable, you will need to report that modifier. For the technical aspect, this is all the administration, administrative work. It's the owning of the equipment itself. So this is more of the facility cost. So like if you're doing, you know, a study in the hospital setting where they own the equipment, the hospital is going to bill for their technical piece of the, of what's being reported. And then the physician would report their portion with appending that modifier 26 for the professional side. All right. So supervision guidelines. I always get a lot of questions with this, especially, you know, with how they've, and again, we'll cover this as we go through, but, you know, like with APPs, like what are they allowed to supervise now. So we'll cover all that. All right. So these are the main three supervisions that we see on the, from Medicare perspective. So general supervision means the procedure is furnished under the physician's overall direction and control, but their presence is not required during the performance. And that's assigned a status of 01 when you're looking at the fee schedule. Direct supervision means the physician must be present in the office suite and immediately available, but they do not have to be physically present in the room where the procedure or service is being performed, but they do need to be in the office suite. Personal supervision means the physician must be in attendance in the room during the performance of the service. Again, you can find the details for each CPT code that you might be looking at on what the physician supervision requirements are assigned. There's a column listed on the fee schedule that gives you that level of assignment for each code. Again, these are just like a breakdown of the most common ones that we see. So as just a straight zero would be a procedure. It's not a diagnostic test or procedure. And it's not subject to the physician supervision policy. The 01, 02, and 03 we just covered. And then the 09 is concept does not apply. And we'll kind of cover what that looks like on the fee schedule. So this is a snapshot of the Medicare physician fee schedule and what it looks like when you're simply looking at the supervision requirements that are assigned. So you can see here I pulled in some of our pacemaker services, whether it's in-person or interrogations or remote services. And then again, you can see what the supervision requirements are for each CPT code and whether or not you're looking at the global code, the technical aspect only, or the interpretation only. All right, so let's talk about some APPs. So effective January of 2021, Medicare did put out a article on the revised guidelines for supervision requirements for APPs. So what they state is it's authorized for the personnel to perform the diagnostic test under the supervision collaboration requirements. Applicable to their practitioner benefit category pursuant to state scope of practice laws. So that's something we say a lot when it comes to APP supervision billing. It's going to depend on that state and what their laws are. So I do see that Medicare does allow an APP to now do an implant of a loop recorder now. So that is allowed. But again, that could be different just depending on the state you're in. But they are allowed to personally perform that now. So same with as far as supervision goes. It's just going to depend on the state and what their laws are. From a Medicare perspective, though, you know, they are saying that they're authorized to personally perform those tests and it falls under that state scope of practice. All right, so example of supervision guidelines and how it gets applied. So we're going to look at general supervision first. So that's when it's assigned that 01. So again, this is what a, this is remote, a remote device service. These are billable once every 90 days or 91st day, we say. So you can see here, this is our pacemaker personal interpretation, our defibrillator. And then the 93296 is for the technical download. And this is applicable whether it's for a pacemaker device or a defibrillator device. So when you see that it's assigned a 01, that means, you know, general supervision is required. The physician is responsible for the overall supervision and training of the personnel doing the download, but they do not have to physically be in that room and present while it's being done. So a lot of times when you're looking at a device clinic, they may have registered nurse or a medical assistant that may be specifically trained in doing these downloads. So a lot of times they're doing them and then they send that download to the provider and then they're going to do their interpretation and bill for that piece. If you have staff that is doing that download, you can bill that technical piece of the service. Sometimes practices may work with the device companies itself and maybe the vendor is doing the download. So it's really just going to depend on how your clinic is set up. But again, if you're having your staff that is doing it, then you can bill that 93296 and it is assigned that general supervision. Direct supervision, this again means that the physician has to be in the office suite, but does not have to be in that room. So here we're looking at a pacemaker single lead in-person programming evaluation. So you can see here for that technical piece of the service, it does require that the direct supervision is being provided. So that physician would need to be in the office suite, but not physically present in the room while it's being downloaded. And then again, the global service itself has the concept does not apply assignment along with the professional interpretation only. Again, if you're working with a device vendor and they're in the office setting at the time and they're doing that download, then they would bill the technical code piece of it and then your provider would be billing only the professional interpretation. If you have staff that's doing that download, then you would just bill the global code itself with no modifier. All right, so now we're going to break down some of the different testing that we look at with regards to arrhythmia testing. We'll start with covering our ambulatory monitors. So these are defined as small portable electrocardiograph machines that are able to record the heart's rhythm. There are multiple types of monitors available. As you can see here on the slide, each has a unique feature related to the length of recording time and the ability to send the recordings. So we'll cover the specifics of each of these different types of monitors as we go through the next several slides. So we'll start with our EKGs. This is one of the most common services performed. You may see it abbreviated with EKG or ECG. Those are the two common acronyms there. This is a test that measures the electrical activity of the heartbeat. With each beat, the electrical impulse travels through the heart. This wave cases the muscle to squeeze and pump the blood from the heart. A normal heartbeat in an EKG will show the timing of the top and lower chambers. A 12-lead EKG picks up sustained arrhythmias, but sometimes the arrhythmias may not be sustained. A common question I do get when it comes to EKG reporting is, can you bill an EKG and a device check on the same day of service? These do have an NCCI edit with Medicare. It's going to depend on why they're both being performed and what that medical necessity is. Let me give you an example of when it would be appropriate to add the modifier. Let's say the patient comes into the office for a regular follow-up visit with their EP provider. They're being seen for follow-up for their AFib. They have maybe a dual-chamber ICD. The patient is now complaining of chest pain, which is a new complaint for that patient. The patient's already scheduled in the device clinic to have their ICD interrogated that same day. Now that the patient's complaining of chest pain, the provider wants to go ahead and do an EKG just to see if there's maybe any type of ischemic abnormalities going on. In that case, that would be a scenario where both would be supported because, again, they're coming in the office, being seen for their history of AFib and that dual-chamber defibrillator being there. Now with the new chest pain, they have a new concern with wanting to see if there's maybe something new going on with the patient, so they do that EKG. Again, in a scenario like that, when they're unrelated, you have that medical necessity documented. You can add that modifier 59 or, if your carrier prefers an X modifier, to that EKG. Otherwise, the EKG will bundle with that device check done the same day. This is our reporting when it comes to EKGs. The 9300 is for the global code, or 9300 is the global code. If you're in your office setting, you own your equipment, you're going to bill the global. If you're billing it based off of the component codes, that 93040 would be for the technical piece of it. That's for the equipment and the tracing only. Then, if you're doing the interpretation only, which is commonly what we see in our hospital settings with EKGs, then you're going to bill that 93010. Again, it's just going to depend on your place of service and whether or not you own that equipment or not. 93040 is what we typically call a rhythm strip. It's one to three leads is being evaluated. It's not a full 12-lead EKG. Most carriers bundle this if you're doing an E&M same day. Most carriers do not pay for this anymore. It's been several years since I've even seen one reported, because most times when you're in a hospital setting, for instance, they typically will do these one to three-lead strips. As a follow-up, typically the physicians are seeing the patients and still treating them for their ongoing conditions. Most carriers will bundle that, But if they only are doing that that day, then of course you'd want to report your service. So 93042 would be for that interpretation and report only. All right, so Holter monitors. So the purpose of this study is to evaluate the patient's heart rhythm during a full daily cycle. A lot of times they'll come into the office and have the device placed in the office by a technician or a medical assistant. So they'll place those ECG leads on the patient's chest and the patient will wear that recorder for up to 48 hours. During that time there's continuous rhythm recording and storage that's being documented. The patient would then return to the office and return the device and then that technician is going to download all that data from the time the patient wore it and then that would go to the physician to review all that data and then give a professional interpretation of that up to 48 hour study. So this is the CPT reporting options. Now reporting can vary just depending on whether or not you have bought your own Holter equipment and you own it all or if you have contracted with a vendor that does the recording the scanning and analysis piece of it. Most practices that we work with they typically don't own their own Holter equipment so what they do in that case when you're not reporting that global code the 93224 includes all three of these codes. So if you're billing that full code that includes everything that's documented here whether it's the recording which includes that connecting and disconnecting the scanning and analysis and then that physician report. Most practices are billing for the hookup which is that 93225 and then they're billing for the interpretation so you're billing that component codes only. Again it's just going to depend on how your practice is set up and what the variabilities are with that and then if it's a third party vendor that's monitoring that you know while the patient's wearing it and they're the ones that are scanning and sending that analysis with the report to the practice you know once the patient's done they would bill the technical piece of that. CPT does state for a Holter monitor if the if it's less than 12 hours of continuous recording because the service is up to 48 hours so if it's less than 12 hours then they want they state to append that modifier 52 for a reduced service in that kind of case. I haven't seen it that a scenario like that in a very long time. What I typically see now with the monitoring of these services a lot of people are using those extended monitors which is the codes we're going to cover next. These used to be the zeo pat we called them the zeo patches they were category three code several years ago and then they did graduate into a category one code and then they decided to split them off depending on the recording time frame that the patient has the system on so that's why you see two different options here. So the 93241 is the global code and that's if the recording is more than 48 hours and up to seven days. The 93245 is if it's more than seven days and up to 15 days so it's going to depend when you're looking at coding for these services it's going to first it's going to depend on what the physician ordered so did they order a seven day extended monitor or did they order a 14 day extended monitor and you know you're going to need to check that you know for when you're billing for that hookup. Definitely don't see many of the component codes being reported for these with the groups that we do work with. A lot of times obviously they have a third party vendor that's doing that scanning analysis with the report so they bill for that piece and then the provider is billing for their professional pieces that they provide so if that's the the scenario that your practice works with then you would bill for the hooking the patient up if you do hook them up. Sometimes the systems are mailed to the patient's house so it's going to depend you know if the patient does have the system placed in the office setting by one of your you know staff members then you can bill for that hookup essentially but you want to bill for the correct hookup depending on what the physician orders and then later once the analysis and reports ready for the physician to review they will document you know how long the patient or the device and and what that interpretation is so again you got to pay attention with these services on what the time frame was that they had the system on and how long it recorded. All right now there's two different types of monitors we call event monitors that can record up to 30 days so that's the time frame assigned for these so we'll start with the event monitor and then there's another one that we call MCOT which we'll cover that one next but with the event monitor it's a small portable battery powered machine that's used by a person to record electrical activity over a long period like I said these can be up to 30 days the person may keep the recorder for several weeks each time symptoms are experienced the patient will press a button on the recorder so it records that electrical active activity sample as soon as possible the sample is then transmitted to the doctor's offices for evaluation so again these do have the capability to be worn for up to 30 days to record that patient's rhythm. So with the global reporting code 93268 reports all components of the code again most practices will use that third-party vendor that's doing that analysis with the transmission so you would break these down into that component reporting so the 93270 is for the recording that includes the connection the recording and the disconnection and then your physician's review and interpretation of that study would then be the 93272. Again this is CPT notes that is in your book that's printed within the CPT code guidelines so it just talks about if there's implantable patient activated event recording then you would see these other codes and this 332085 is an implant of a loop implant is what we typically call it or an implantable loop recorder so that's when the patient actually has it implanted and they're not wearing it externally so different with the reporting options with that. All right so our MCOT are what's defined as that mobile cardiac outpatient telemetry monitor so this one is allows for continuous heartbeat monitoring as you go about your daily activities most people that have this can wear it anywhere from 7 days 14 days or it can go all the way up to 30 days. The device consists of a small sensor that's attached to three electrode pads the sensor then sends each heartbeat to a handheld monitor that can be tucked into the pocket or purse when the monitor detects a heart rhythm problem whether or not that patient feels it or not it will automatically transmit to the monitoring center and then at that center which operates around the clock they have certified cardiac technicians that analyze each transmission and then they will respond appropriately to each event and transmit that report to the physician so that's the difference between that event monitor and then that mobile cardiac telemetry and then with the CPT reporting there is no global code for this so the 93228 is for that professional interpretation by the physician the 93229 is that technical piece which you know the third-party vendor that may be doing the actual monitoring while the patient's wearing it they would bill for that. This is just a cheat sheet I kind of put together that breaks down every all the codes we just coded so you know created this in hopes you know it could help help some of the coders out there that need it I know I use it a lot so I just have the codes handy for me when I'm looking at these so wanted to share with the Medaxeum community. All right so we're going to now move into our cardiac device implant monitoring services so again last month or might have been the month before I covered the procedural piece of this where you're coding for the actual device implants so now this is the monitoring for those implantable devices so we'll kind of break down and define each device briefly before we move into the coding. So with a pacemaker it's a small device that's placed in the chest or abdomen to help control abnormal heart rhythms. This device uses electrical pulses to prompt the heart to be at a normal rate. A pacemaker can relieve some arrhythmia symptoms such as fatigue and fainting again so it's just going to depend on what why the patient has it and what condition its purposes to treat and then there's also leadless pacemaker systems so we've had the right ventricle leadless pacemaker system for several years but we do have new codes now for a right atrial leadless system and then a dual chamber leadless system so we'll cover the coding on those as far as it goes for the monitoring of those but these are unlike the conventional pacemakers so a leadless pacemaker is placed directly in the heart without the need for any surgical pockets and pacing leads to be implanted. The device is much smaller than the conventional pacemaker system it's compromised of a pulse generator that includes the battery and it has a steroid eluting electrode that sends pulses to the heart when when it recognizes that the heart's having a problem with arrhythmia. And then our defibrillator systems there's two main types that we see typically we do refer commonly refer to these as ICDs so this is a specialized device that is designed to directly treat many dysarrhythmias. It's specifically designed to address ventricular tachyarrhythmias. ICDs have revolutionized the treatment of patients that are at risk for that sudden cardiac death due to that v-tach or v-fib. The device does deliver pacing signals and shocks as needed due to that patient's condition. So we also have a subcutaneous implantable defibrillator now and we've had this code for several years so this is done implanted a little bit differently. They actually tunnel the lead whereas it's not implanted like with the traditional defibrillator so the it does require of course that pulse generator and then the subcutaneous system just a little bit difference with with it. It cannot pace the heart whereas the transvenous system can. The transvenous system may be inserted in a single chamber where it's pacing maybe only the right ventricular or in a dual chamber where it's pacing both the atrium and the ventricle or it can be as a biventricular system where it's pacing the left and right ventricles. That subcutaneous system it only has a single lead and it's tunneled into that rv chamber basically. The transvenous device the common one that we see it uses a combination of that anti-tachycardia pacing, low energy cardioversion or defibrillating shocks again used to treat that ventricular tachycardia or the v-fib whereas that the subcutaneous system can only provide that defibrillating shocks. Leads defined this is actually from CPT guidance and this is information that is printed in the book. This is how they define the number of leads so a single lead means pacing and sensing functions in only one chamber of the heart. A dual lead system would mean it's pacing and sensing functions in two chambers of the heart and again with our biventricular device this could you know or I'm sorry skipping ahead multi-lead would mean it's sensing and functioning in three or more chambers of the heart. So again this information is printed in your CPT book so again it's just going to depend on the type of device the patient has and you know how many chambers they may be having the the leads implanted. Other systems so the implantable cardiovascular monitor or ICM devices if a provider is unable to diagnose the cause of a patient's symptoms with you know maybe one of those external recording devices like that we just covered they may consider an implantable cardiac monitoring system. That's a tool that will monitor the heart's electrical activity and it helps the provider identify a cause of the patient's system. There's also a subcutaneous cardiac rhythm monitor this is the most common one we see that's when they're doing that loop recorder that I referred to so that can it's implantable. The device itself is pretty small they can actually implant these now in an office setting and they these used to have a 90-day global associated with them after the implant but that they updated that several years ago because like I said these are very easy to implant a lot of times patients don't even get moderate sedation for these a lot of times they'll just apply a local anesthetic to the chest and they'll implant the device it's about the size of a paper clip it's pretty small but it does provide continuous monitoring a lot of times they implant that device if the patient may have had a stroke and they're not sure if the patient has underlying atrial fibrillation that could have been the cause of the stroke so I see a lot of those implanted for that reason or they could have you know be having issues of palpitations and the external monitors that they wore maybe they had a you know a Holter monitor or even a vent monitor and it didn't really pick up anything but the patient's still complaining of symptoms so they may go ahead and opt to place you know one of those devices in that case too they do eventually run out of battery life so sometimes you know the if the patient's been no symptoms or no issues found on the monitoring device you know once it's at the end of its life the provider may just opt to remove it and not replace it at all it just varies sometimes those devices will detect an issue and then so they may end up getting a permanent device later so you know I've seen where these devices can pick up that the patient has tachybrady syndrome and now they need to get a pacemaker a permanent pacemaker put in for that reason so you know at the time of them removing this system they would go ahead and do the implant of that permanent device at that time so again it just depends on what they need it for but these will both both of these devices will provide you know longer recording time for to help properly diagnose and treat the patient all right so we have in-person interrogation and in-person programming evaluation services that we're going to get into so again all of this information is printed in your cpt book so as we go through it you know we'll cover what all of it means so interrogations are defined as an evaluation of the patient's implantable device store details about the system are retrieved then the information is evaluated to determine the current programming of the device and to evaluate certain aspects of the device function such as that battery voltage and the rhythm treatment settings so this is the components in your cpt book that are listed for an in-person interrogation so again depending on the type of device they have the requirements could be you know a little bit different um so again for all of them you know the programmed parameters is you know part of evaluating that device um you know if you have a pacemaker or defibrillator of course the how the leads are programmed the battery a lot of times you get details of the battery life expectancy once it starts approaching the end of the life of the battery you know you'll get details of that in the report the capture and sensing function sensing function and then again that heart rhythm for pacemaker for that defibrillator you know if they have any history of that v-tach or v-fib they're going to be looking at those details too all right so this is our in-person interrogation cpt code reporting depending on the type of device you have so if it's interrogation only um you know and you have these you know different requirements that are supported in your report um you're you got your 9-3-2-8-8 for your pacemaker or your right ventricular leadless pacemaker um 9-3-2-8-9 for your defibrillator um 9-3-2-6-1 is for that subcutaneous defibrillator and then if you have that implantable cardiovascular monitoring device that's 9-3-2-9-0 and then your loop implant or your ilr is your 9-3-2-9-1 these do break out into whether it's a component code modifier 26 for the professional piece or the technical tc component um so again if it just depending on how you have your device clinic set up um if you have a device technician that's coming into your office and doing those downloads then they're going to bill for their piece your provider would then append modifier 26 to bill for their interp only but again if you're billing for the whole thing because you have staff um that's doing the download um then you would just bill it without the modifiers so this is cpt reporting instructions so cpt guidance on in-person interrogations is you may report this service per data service performed it cannot be reported on the same date as a programming evaluation and it cannot be reported on the same date as a remote interrogation guidelines also state that if an in-person interrogation is done and they've also had a remote monitoring um service performed within that 90-day period then the in-person interrogation would be included in that remote monitoring period so if you have your patients on a remote um you know monitoring system where you're you know doing their your their remote downloads every 91 days um and you do an in-person interrogation within that time frame most carriers will deny that um service since they will bundle it in now your programming evaluations they do not bundle so it's again going to depend on the level of detail um in that download and what was actually evaluated all right so programming evaluations are a little more work than just an in-person interrogation remember the programming evaluations are also in-person only so we're going to cover the different requirements coming up but these are billable within that remote device service so keep that in mind that big difference between that with the reporting cpt reporting is also going to depend on the type of system and the number of leads um you know or chambers that are evaluating so you can see the components of the programming device evaluations and how much more detail there there is for these systems there is no programming for an icm device but there is for that subcutaneous or the ilr so with our pacemaker defibrillators you can see with the interrogations only we had the first five bullets here for these services you can see every this is the additional work that is being evaluated with that device and why it would fall under a programming evaluation so a lot more work goes involved with these so again, keep that in mind when you are looking at the difference between the reporting. These are also applicable to the component code only or whether or not, you know, depending on how your device, your clinic is set up again, if you do have a device technician from the vendor coming in the office and they're billing for the technical piece of it, then you would append the modifier 26. Now, with those leadless systems that we talked about, if they're doing a programming evaluation, there is new Category 3 codes for those depending on whether it's a right atrial leadless system only or if it's a dual system where it has that right atrial and right ventricle leadless leads implanted. If it's just a right ventricular leadless system, it still would fall under a single chamber regular CPT code with the 93279. Defibrillator, again, it depends whether it's a dual lead or multi, and then again, with your programming, you have the subcutaneous defibrillator here and then your ILR system. The rule service rules are different, though. These do allow to be reported per data service as long as medical necessity is being met. They are also allowed to be reported during a remote monitoring period. So remember, these are done only in person. It is up to your providers and device technicians to understand those required components and to make that distinction between whether or not it's only supportable with an interrogation only or if the programmed evaluation is supported. Big key difference is they are actually interacting with the device. They're not just simply downloading the data. Adjustments can be made if medically necessary, but sometimes there's not adjustments needed. So that's why we call it programming evaluation, because they are meeting all the components of a programming service, but they're not actually needing to make changes, you know. They could evaluate all those components and the patient's stable, so they're going to leave everything as it's currently set, but it would still support, you know, reporting that programming service. All right, and then with that, I did create this, too. This is actually data from the CPT book itself, and, again, I used this myself, and that's why I created it, because it is helpful. So it lists the requirements when we're looking at a pacemaker or defibrillator, what the required components are for the interrogation only, and then, again, if they do any additional work, you know, and it's meeting that programming evaluation, then, you know, the additional required elements that are needed in the documentation. So, again, they don't always have to make changes, but if they are evaluating these additional areas, then, you know, you have more than just an interrogation only in your report. All right, so we're going to move to the remote device services now. So these are on a monitoring period. It is important to stay within those applied period guidelines. You want to make sure that you're able to capture the clinic schedule to keep the patient on the period dates allowed. The device information is sent automatically, or it could be manually, you know, just depending on the patient and depending on, you know, what's going on with them. Sometimes I see downloads done within the monitoring period allowed to be reported, but it could be because maybe the patient's now in the hospital and the hospital wanted to have the patient's device evaluated or maybe the device captured an arrhythmia that was concerning, so there would be a report sent to the provider to review to see if the patient needs to come back in the office and have their device reprogrammed or, you know, address the condition or the arrhythmia that it captured. So it's just going to depend. If it's within the downloading period, then, you know, it's not going to be a billable service, which happens. You know, that's the purpose, though. It's to keep monitoring that patient ongoing and to make sure they're staying stable. All right, so components of the remote interrogations for the, you know, remote services that we're talking about, they're the same exact as whether the patient is in person having an interrogation only done. So, again, you're going to look at the program parameters, the leads, the battery, any capture and sensing functions, and any heart rhythms that are detected during that device. So same exact requirements, whether it's in person or remote for just interrogation only. With the remote services, the codes reported are broken, again, into that technical component and the professional, there is no global reporting with these services. Well, there is now with the ICM and the ILR devices. So as far as talking about our pacemaker defibrillators, though, the codes are broken out. So you have, if you have a technician on staff that's doing that download, then you would bill that download code, which is that 93296. And then just depending on whether it's pacemaker or defibrillator, you would then bill for that professional component for the interpretation that your provider gives. So this is the CPT reporting. So, again, the technical download is the same, whether, you know, it's pacemaker, defibrillator, or that subcutaneous defibrillator. Your professional code is what's going to change just depending on the type of device. So if it's that leadless right ventricular pacemaker system, then you're still going to bill the 93294, and then your technical download would be the 96. Defibrillator's professional is going to be the 95. The implantable cardiovascular monitor and the loop implants, they did have a G code that Medicare created. They deleted that at the beginning of the year. So these codes went into component reporting. So if you have somebody else, you know, doing your download that's not on staff, then they're going to bill this, you know, code, the 93298. They're going to append a TC modifier. Your provider would then append a 26 modifier for their professional intern. So these two codes do now have component or the global code, I meant to say, and whether or not the 26 or the TC are applicable. Now, if your clinic's doing the full thing, you just bill the full component code now. 93298, that report that supports your professional component and the technical download. All right, so again, an interrogation is an interrogation, whether or not it's in person or remote. Remember, those requirements are the same. Once a remote interrogation has been billed, any in-person interrogations performed within that 90-day period or 30 days, so the ICM and the ILRs are on a 30-day period, your pacemaker and defibrillators are on a 90-day period. So it's just going to depend on the type of device. But remember, once that remote interrogation has been billed, any in-person that's performed within that reporting period would be not separately billable. CPT has language to say not to report if the monitoring period is less than 30 days. And again, that 90-day service period applies to the remote device interrogations of that pacemaker or defibrillator. Your 30 days will apply to your ICM or your ILR systems. And again, this is just breaking that down. This is, again, CPT language in the book. So for an ICM system, there is a note. But remember, that one is 30 days, not 90. It does have notes in the CPT rules that states it does have to have a minimum of 10-day wording per CPT. These types of device usually will monitor – they're usually used in cases where a patient has congestive heart failure or pulmonary hypertension. It monitors that fluid and all that stuff in the heart. So sometimes a patient may have both. They may have an ICM device and a permanent device, whether it be a defibrillator or pacemaker. So it does have different recording in what it does. ILR is the same thing. It's reportable every 30 days. Most carriers, why we add that extra day behind it is because they may say, oh, you're still within that reporting period, so they made it ISO. Like with the 90 days, we say don't bill until the 91st day. Same thing with the 30 days. Don't bill again until the 31st day. And it also does have a minimum of 10-day language in the CPT guidelines. All right, so telephonic pacemaker services. I don't see a lot of these done anymore, but if you are performing these still, we'll kind of break down what these are. So how they're defined is service of transmission of an electrocardiographic rhythm strip over the telephone by the patient using a transmitter and recorded by a receiving location using a receiver or recorder, or what is commonly known as a transtelephonic pacemaker monitor. So the downloaded data is done a little bit different, whether, you know, or not it's just being done by a technician and all that. So it's a little bit different. Like I said, I don't see a lot of these done anymore. But if you are still reporting these types, you know, we'll keep covering. So no ICD checks over the phone. This is just for a pacemaker system. Information obtained is more limited than a remote interrogation. The 93293 is for that pacemaker phone check. And this is reportable with up to 90 days also. So it doesn't matter whether or not it's a single, dual, or multi-system. If they're doing that telephone download, then it's this 93293. Again, this does carry that 90-day service period. In-person interrogations as well as programming evaluations are billable within the reporting period for this service, and it does have that 30-day minimum requirement for CPT. Peri-procedural services. Definitely get a lot of questions on these, too. These are services that could be done if the patient's also having a procedural service provided. Sometimes if they have a device, the device may need to be reprogrammed or even turned off while the patient's having the procedure. So you can bill for these if allowed. And I'll cover some certain scenarios where it's not allowed. But the 93286 is if the patient has a pacemaker, and then the 93287 is if they have a defibrillator. And you can see how they're defined. It's an evaluation and programming of a device before or after a surgical procedure or test. And again, it doesn't matter if it's a single, dual, multi, leadless, the same with a defibrillator. So this is the reporting. So it covers some kind of guidelines. So a programming device evaluation is performed in person in order to test the patient's device function and select the most favorable program values during that service that's being provided. Patients with a previously implanted pacemaker or defibrillator system may require adjustments of the device to the patient-specific settings prior to a surgery test or procedure. The device system data is interrogated to evaluate the battery, the leads, and the sensors, as well as the stored patient and system measurements. If necessary, the device is programmed to settings that are more appropriate for that procedural service or testing to be performed. Most times a post-procedural evaluation will also be done to the device. So guidelines do allow that this can be performed pre and post evaluation. So what that means is there is a medically unlikely edit or an MUE, an assignment of two units. So if they program the device before the procedure or test, and then they reprogram it after that service has been completed, you can build this twice. Most carriers want, you have to check with your carrier policy. What I tend to see is most of them want it reported individually, and then you append modifier 76 to the second one, because you're reporting them on the same day. Some, just depending on your payer, though some may just want you to bill it with two units. So again, it's going to be payer specific, but most of what I see is they prefer to have that 76 modifier appended to the second one. And real quick, just to touch up on. So with the peri-procedural services, when it comes to looking at our EP services as a whole, and I did cover this on the other two webcasts that we did in our series. So there is some NCCI edits. So when you're talking about ablation services, for instance, and the patient does have a device implanted, Medicare actually specifies in their NCCI manual that if the patient has a, if they're having a pulmonary vein isolation or a ventricular tachycardia ablation, and they have a device that's programmed, the service cannot be billed. Where it doesn't bundle on the ablation side is if you have an AB node ablation being done or an SDT ablation being done. If the patient does have that device implant and they're evaluating it and, you know, before and after the procedure's done, you can bill it with those two ablations. So again, wanted to point that out with the ablation services. And again, I did cover it in that webcast. So if you want to go back and listen, you're definitely more than welcome to, but there are some rules with those. So just keep that in mind when it comes to the periprocedural services. So we'll cover some FAQs now with Medicare. This is a big one that we get asked a lot. So this article was revised and released back in 2019, but it did clarify date of service, because this is still a common question. Like what is the date of service I'm supposed to bill? So what they state in the article for the cardiovascular monitoring services is there are different, many different procedure codes that represent the cardiovascular monitoring services. These can be identified as professional components, technical components, or a combination of the two, which would be that global reporting. Some of these monitoring services may take place at a single point in time or others may take place over 24, 48 hours, or even that 30 day period. What they, what we bolded in red here is, this is all word for word, what's in the article. The determination of the date of service is based on the description of the procedure code and the time listed. So when the service includes a physician review and interpretation, along with that report, the data services, the date the physician completes that activity. So when you're looking at your Holter monitors, you're not, you know, those can be up to 48 hours. They may have had the service placed on the 15th, but your physician's not actually reviewing that download and doing their interp until the 18th. So when they complete that and you have that report ready for the professional interpretation, your data service would be when they completed that, which would have been the 18th. So again, that's what they're stating here. Now, if the service is a technical service, the data services that the date, the monitoring concludes based on the description of the service. So again, it's just going to depend. Obviously there's many reporting options, depending on what type of monitoring service that they're having. So then again, they give an example here. If the description of the procedure code includes 30 days of monitoring and the physician interp and report, then the date of service would be no earlier than the 30th day of monitoring and would be the date the physician completed the professional component of the service. So again, when they do their interpretation and sign it, that would be your date. Some vendor FAQs, again, some guidance is going to vary, just depending on the type of vendor. You're also going to want to check with your non-Medicare payers, see what they have policies on. Again, there's no set answer for this recommendation is to keep it consistent though. So that way, you know, everybody's on the same page with how you report the services. So again, you can check into your other payers and see what, what type of requirements requirements they may have. Excuse me. So frequently asked question. We did cover this earlier, but again, it is a common question I get. So can you build that EKG or I'm sorry, we covered the EKG. This is a different common question. Can you build an office visit and an device interrogation same day? So again, you, with an E and M reporting with any type of diagnostic service, doesn't matter if it's related to arrhythmia or, you know, if it's an echocardiogram or nuclear stress test, any of that, you have to have a distinct separate reason for the E and M encounter. So if you have your patient in your office for followup, you know, and, and maybe they're, maybe they're complaining of symptoms. So you want to go ahead and do a device evaluation at a time at the same time, you know, to see if maybe the device is capturing anything. You know, I have that medical necessity to append your modifier 25 to your E and M is basically what it comes down to. So if you do both the same day you know, Medicare is not going to, or any of your payers, they're not going to pay for both if that E and M does not have the 25. So you got to make sure your 25 is supported. If not, then you would just report your device service for that day. Can we bill for device monitoring services during the surgical global period? So yes, you can bill for device evaluation services during the surgical global period as diagnostic services are not part of the global surgical package. You still got to have medical necessity though, for evaluating the device, you know, if they're not on a remote type system or you know, whatever the medical necessity could be. So you can though, that's the point if the patient just had a pacemaker fit in and they're within that 90 day global for the procedure and they're coming in and, you know, having a complaint. If you do that download in person and you evaluate the device, you can bill for that at that time, as long as that medical necessity is there. All right. So what guidelines do you follow with this? So CMS obviously has many manuals and instructions out. You definitely want to check with your, you know, whether there's a national policy that could be out local coverage, determination definitely Google with caution. You know, I, I Google a lot too. So just make sure you're, you're cautious with the information that you find to make sure you're verifying it's correct. Don't just Google it and run with it. Definitely. You definitely want to make sure you're checking your authoritative resources with Medicare the American medical association and following that guidance references versus rules versus guidance. You know, again, you want to follow your authoritative sources first over any kind of recommendation be skeptical. Again, like I said, don't just Google something and run with it. You want to verify it's correct information. And if you're not sure you can check always check with your compliance team, you know, or, you know, any any type of, you know, attorneys if you may have that on, you know, within your organization that kind of stuff. So some key takeaways. There's not set standards for reporting formats, we are going to cover what some of the case examples so you'll kind of see what that looks like. Most practices use vendor templates, when it comes to these types of services. So in those reports, there's usually an area that identifies whether the service provider is in person or remote. When we're looking at our device services that that'll help establish what exactly was performed. Again, audit experience has also confirmed that the physician order and balance signature are critical to these services. There should always, always be an indication listed in the report as well. This helps to establish that medical necessity for the study. You also want to clearly see any abnormal findings documented in the provider interpretation if there are any. And then again, try to distinguish whether or not an interrogation versus programming evaluation is supported. It is critical, you know, that your provider and the technicians that are doing those downloads understand those required components. Top five revenue cycle tips. So again, touch up on the programming does not always equal to adjustments being needed. It's just actually interacting with that device itself. Defying the processes and schedules to meet those defined timeframes in your device clinics. If you provide an in person interrogation inside that remote monitoring service period. Just remember, it's not going to be separately billable. You can build a programming evaluation if that is supported. If you do that technical component. Remember to submit the technical code as well as the professional unless it's the The full global code itself, then you don't need to worry about pinning those modifiers. And then don't forget about your multifunction devices like those ICMs. Like I said, sometimes the patient may have a permanent system and then they also have this ICM device in place. As well. This was just another little cheat sheet here on diagnosis reporting, you know, the patient's having a device monitoring service. They're asymptomatic with no abnormal findings documented. These are the common diagnosis codes reported It's going to depend on your state and carrier. I do see a variability across the country with these codes. Some carriers only want the Z code on the device service. Some want the reason for the implant, then the Z code as the secondary diagnosis. So it's just going to vary. I do see it different across different states. So just check with those payers and see what their, you know, preferences are with the reporting of that. Alright, so let's cover some case examples. So this is an office EKG. Reason why I said earlier. So a lot of times when you're looking at an office like a an EKG where you own the equipment and stuff. You're looking at the strip. The computer is always going to give a reading of this. So you can see here. I know it's kind of small, but it says non specific T abnormality. And it does show it's abnormal. This is the computer reading. So a lot of times what I see, you know, if the physician's going to do their interpret a full strip. A lot of times they'll hand write on the top of this. And then they'll hand sign it and then that gets scanned to the patient's chart. Other times they'll document within the patient's chart. A separate interpretation. So that's what we have here. So this is the computer reading of that EKG strip in the office. And then the physician documents within that patient's chart. So the reason for the study was they have a history of that proximal AFib And you can see here, you know, they they date and sign it. They don't agree with the abnormal finding. They state the EKG is normal and it does show the patient's in sinus rhythm. This here was the order for the service. So again, you always want to verify, even if it's an EKG, it still falls within that diagnostic study guidelines. So you got to have an order for it. You need to have, you know, a professional interpretation and signature also And then for that, the reason for the study was for the AFib, even though it was normal, that was the medical necessity and why they ordered it though. And then we own the equipment. So we're building the full code. So that 93000 All right, so case example number two. So this is an extended three day monitor interpretation only. And you can see here, this is the first page. So these monitors are multiple pages long because you got to remember it's doing continuous recording over several days. And it can go all the way up to 30 days, just depending on the type of device. Usually at the top, you're going to see it defined. So like here we have an extended Holter report. And you can see here it was prescribed for three days. The diagnostic recording time was the three days. The reason for our study was for dizziness. And then down here you can see our physician hand interpretation of the study and then their signature and their date. So again, a lot of times there's a preliminary findings here. Sometimes the physicians may not agree with that. Sometimes they'll look at it and they'll say the study still within normal limits. Here it does say they had occasional APCs and PVCs. But overall, it was a benign study. And then again, it says patient triggered associated with that clinical that PVC found So here we have the up to three, it was greater than 48 hours, but less than that, within that greater than 48 hours, up to seven days. So we have 93244 for our professional interpretation and with the provider that then documenting the APCs and the PVCs. All right, so this one's MCOT interpretation. And again, these studies are pretty clear. If it's an event monitor, it would state event here instead of the MCOT. So always pay attention to the strips that are sent over. So you know what type of device you're actually looking at for your Again, multiple pages. No way for me to download all that to show you guys. But the overall summary on the first page is, you know, what the physician is looking at, along with the actual strips that are sent over. So again, multiple pages. No way for me to download all that to show you guys. But the overall summary on the first page is, you know, what the physician is looking at, along with the actual strips that are being looked at. And these can be up to 30 days. So remember that this patient had it on for 14 days. And our reason for the study was for the proximal AFib. So physician interpretation was documented separately within the chart in signs. So this was what they documented for the findings of the study. Sinus rhythm with that proximal AFib. They also said tachycardia with a maximum rate of 90 beats per minute. Total duration of the AFib was 18 hours with an 89% burden. No sustained ventricular arrhythmias or Brady arrhythmias were found. So with that, our CPT reporting is going to be 93228. That is for our professional interpretation of that MCOT. And then the study did find the atrial fib along with that tachycardia. All right. Case number four is an event monitor interpretation. So you can see up here, it now specifies our type of system the patient had on. Again, this period was 30 days. And then again, the overall summary that was sent in the report. And then our provider's interpretation here, they state it was an abnormal 30-day event monitor. The patient was in sinus rhythm with proximal rapid atrial fibrillation and tachycardia with a maximum rate of 120 beats per minute. Total duration of the AFib was a 75% burden. This one also did not show any ventricular arrhythmias or Brady arrhythmias. So this one again, our reporting, CPT reporting is different. 93272 is for that professional interpretation of the event monitor. And then our diagnosis would be the AFib and the tachycardia that was documented in the findings. When you're looking at these studies, if they do show documented findings, you always want to report those over the reason for the study. A lot of times the reason for the study being done could just be symptomatic stuff like dizziness or syncope or palpitations. But if you have a definitive diagnosis found in the study, you're going to want to build that over the indications only. Now, if the study is normal, then you're obviously going to build the reason for the study being performed. And that is an ICD-10 guideline within the book itself. All right. Case example number five. This is a device monitoring service. And this is what I was talking about with a lot of the vendors. They will specify a lot of times up in the report whether or not it's an in-clinic service or a remote service. And there's a lot of detail in these reports. They will list the type of device the patient has. They will list the date it was implanted, how many leads the patient has. You can see all of the stuff, details being evaluated in the actual download itself. It gives the battery voltage, each lead's sensing and pacing details, all that stuff. So you can see here our device we're looking at is a pacemaker. We see it's in-clinic. We definitely see they have three leads. And we definitely see that they've evaluated all three leads. And then here's the provider's interpretation of that study. So again, all the details listed, whether or not they detected any arrhythmias, whether it's a ventricular arrhythmia or an atrial arrhythmia. If the patient has AFib, a lot of times that device is going to detect that if it occurred during that download period. So it would list that condition as well. It talks about the battery life, how the lead statuses are. If any programming changes are necessary, you'll see that documented. This one did not have to have any done. So this is what I was talking about when you're breaking out the codes and all those requirements needed. You can tell this was more than just an interrogation only. They evaluated the full device and interacted with the device. So with that, because it's an in-person multi-lead pacemaker, we do have 93281. And then we have our Z45018. And then the first page of the study did show the reason for the implant. It only listed the systolic heart failure. We know with pacemakers, there's other reasons, but they only listed that on the report itself. So again, depending on your payer, like I said, it does vary around the country. There's some groups that we work with where the payers only want the Z code, only others where they want the Z code and the reason for the implant. So again, just check those payers. All right. Case number six. Again, another device service. So this one you can see is a remote service. And we can see here we have a defibrillator. And so remember with the remote, it's going to be an interrogation. So you can see here the patient does have three leads. Again, leads were placed at different times. So they did start off with the dual chamber system and later it got upgraded to that multi-lead system. And then again, defibrillators usually are longer reports because more detail is in there with the ventricular arrhythmias and if anything's detected, you're going to have your provider interpretation here, usually at the end. And then you can see here, I'm going to point out the signature date. So the encounter date of the download was 7-10 and that was on our first page up here. You can see encounter 7-10. So that was when our technical download was completed. And then the physician reviewed it and signed it the next day. So following the Medicare guidance, the 9-3-2-9-6 is for that technical download. That's going to be billed with data service 7-10. And then our professional interpretation, which was completed the next day by the physician, is going to be billed with data service 7-11. Again, diagnosis, we got a defibrillator and then the report showed they had dilated cardiomyopathy. These are just some helpful resources that were found. There are also some links within some of the slides itself that take you directly to like an MLN article. There were a couple slides that had links for those specifically. So please refer back to those too, because those are helpful as well. This is just our MedAxian disclaimer. This states that this is for informational purposes only and does not constitute legal reimbursement, coding, business, or other advice. You should always check with your Medicare carrier and consult with your practice's legal counsel for coding and reimbursement advice. CPT disclaimer just covers all the content we coded today. CPT wise came from the American Medical Association. And then with that, I will start looking at the Q&A box and answer a few questions. Again, we will compile all the questions. Give me a couple weeks usually to get that done. I usually have several questions. EP is always a very highly requested topic. But I will get the full Q&A document, including the ones I answer live today. We will get that added to our website and our MedAxian Academy. All right. So somebody asked, can both modifiers 76 and 59 be added to CPT code 93010? So that's a professional interpretation of an EKG that's 12 leads. So this would be more or less done in a hospital setting. So it's going to depend on your payer. I see some Medicare payers want the X modifiers instead of the 59. Both should be allowable regardless though. So if you have, you know, it just depends. So if the provider had, if he's doing an EKG evaluation and maybe the patient had another test done same day. So sometimes I see payers that will try to bundle the EKG reading in if they had an echocardiogram done same day. So again, it's just going to vary depending on your state and your payers and how they process the claims. But like say they have multiple cardiovascular testing done same day. And it even could be like a nuclear stress test because during a nuclear stress test, a lot of times the patient is having that continuous monitoring like an EKG. So it's going to depend on your medical necessity and what you have documented. But if you need the 59 because of there being another cardiovascular test on same day, then just check with your payer, see if they would prefer the X modifiers or the 59. And then if they have multiple EKGs done same day by same provider, that's when your 76 modifier may come into play. So again, if, you know, your 59 modifier requirements are satisfied or your X modifiers, that's fine. You know, you build that. And then if they do two studies, EKGs the same day by the same provider, then that's when you're going to build the EKG twice. And that's where that 76 modifier may be applicable for that second reading. You wouldn't apply the 76 on both EKGs. It would just be the repeat one. So again, check with your, it's payer specific, region specific. So, but examples, like I said, that I've seen is that they have another cardiovascular test being done same day. Some payers may not want to pay that EKG. So if you have medical necessity, definitely still bill for it, but you may have to append that modifier 59 or the X. All right, what should be done when a 14 day monitor is ordered and billed as a 93246, but patient only wore it for five days. So with that, a 93246 is a hookup of an extended monitor that's greater than seven days up to 15. If the patient only wore it for five days, what you would have to do is send a corrected claim for the hookup. And you're going to want to correct it to that 93214. And then you would bill for your professional interpretation. And that's been pretty standard with what I've seen across with the CARES. They'll just require a corrected claim to be sent and they'll still reimburse for that hookup code. All right. Just scanning through some of the questions. Somebody asked, it's a little off topic, but I'll answer it. It's still EP related. So can a loop implant be performed during the same time as an AFib ablation? I do see that happening more often now. Sometimes they could be having that pulse field ablation done. And there's a clinical trial out that some providers are participating in with that. And during that clinical trial, it does recommend that a loop be implanted at the same time. Sometimes they may not be with the clinical trial at all. And the provider may just want to, they did the pulse field ablation, which is a new technique for ablating the pulmonary veins. And it's showing a lot of positive effects with the patient outcome with treating the atrial fib, which is why, I don't know, I see them done a lot more now than just a traditional cryo ablation or, you know, any other ablation technique with the pulmonary veins. But then sometimes the provider may want to surveil the patient longer term to see if that atrial fib is coming back. So sometimes they may still implant the loop implant after that pulmonary vein isolation has been completed. I have not seen any issues with the service not being paid. So they don't bundle together. As long as your provider documents that medical necessity, then definitely bill for both. All right. We've got lots of questions in here. Is there a time when the 93297, that's for that ICM device for a remote interrogation, is there any time that that would be billed with a pacemaker or defibrillator interrogation, remote interrogation? There are times where they can be billed together. So if the patient, like I said earlier, if they do have both devices, they have that ICM device, and they also have that permanent system, there's sometimes within the same report, the provider will document their interpretation of both. So if you have that supported within your documentation, you can bill for both. I know several years ago, Medicare put in an edit, which ended up being an error where they were bundling together, but they did fix that edit. So again, if they do have both devices and you have findings documented within your interpretation, then you can bill. Remember, though, the ICM is on a 30-day monitoring period, and our pacemaker defibrillators are on a 90-day. So it's just going to, again, depend. They may not always evaluate that ICM device every time either. So it's just, variability's there, but if they are both done and supported, you can bill for both. and programming before and after procedure be charged by hospital or is this physician only charge? Those codes do have the 26 and TC modifiers applicable to them. In a hospital setting, what I typically see done is usually there's a device technician from the vendor that is there and they're the ones assisting with that. Your provider's doing, you know, they're billing for their professional piece of it. So I don't see a lot of those done with the global code. So usually in a hospital setting, you're gonna be appending that modifier 26 to the services. Can an MRI programming for pacemaker or ICD be considered for a pre and post? Yes. The periprocedural stuff applies to a surgery or a test. So if you have an MRI and the device needs to be programmed before and after that service is provided, you can still report those codes. Lots of periprocedural changes. Other than the VT ablation and AFib ablations, are there any other EP procedures that cannot be billed with those peri-procedural devices? So yes, your device implants, you can't bill for programming the device as you're implanting it. So that programming of the device itself at the time of the implant is included in the implant that you're reporting. So in a scenario like that, yes, you would not be able to report those services. Now, again, like I said, with the AV node ablation or an SVT ablation, you can bill for the peri-procedural services with those. Are there any medical guidelines for an MCOT versus event monitor orders? Again, it gonna depend. Check your Medicare carriers, those are the best. They give out very detailed, either national or local coverage determinations. Usually when it comes to these types of monitors, there is a local coverage determination out there for your Medicare contractor. So just check that. A lot of times within the policy itself, when you go to the very end of the policy, there's an article that will have a link that you can click on. The article itself will take you to the specifics of how they group the CPT codes, and then they will list out what is payable as far as medical necessity diagnosis-wise for those codes. So again, you wanna check whether there's national or local. If you have a local coverage determination, check for that article as well, because again, like I said, the article will detail out, maybe the event monitor may fall within a group one, and then maybe your MCOT could fall within a group two. And then group one will have all the diagnoses supported, group two will have all the applicable diagnoses supported. So again, check with your carriers, because they do vary. All right, people are still popping in lots of questions. So I will compile, because we are at the timeframe, so I will compile all the questions. Like I said, give me a couple weeks, because there are several, and we will get those posted on our Medaxime Academy as an additional resource for you to refer back to. But I do thank everybody for their time today. Again, be on the lookout for a session four EP series for this year that I will give during our bootcamp session in December. Thanks so much, everybody. Have a great rest of your day.

EP diagnostic arrhythmia

device monitoring services

diagnostic arrhythmia testing guidelines

EKGs

implantable cardiac devices

CPT code reporting instructions

in-person interrogation

programming evaluations

Medicare coverage policies

proper documentation

billing and reimbursement

EP procedures