Holter Monitoring CPT CODE 93224, 93225, 93226 & 93227 and payable DX

Procedure code and description

93224 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional - Average fee payment - $93

93225 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) - Average fee payment - $27

93226  - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report  Average fee payment - $38


93227 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional - $27

Holter

The following is a summary of Current Procedural Terminology (procedure ) codes commonly used for various Holter monitoring procedures performed with a Midmark Holter device. This information is provided only as a guide and is not intended to replace any official recommendations or guidelines, and does not constitute a promise or guarantee by Midmark regarding coverage or payment. Always check with the specific payer for the appropriate use of any procedure  or ICD-10 codes. Physician fee schedule values listed are based on a national average and are rounded for brevity.

Specific payments vary geographically. Codes and rates are subject to change. It is the responsibility of the provider to determine the correct coding for services provided.

procedure  Manual Instructions for Cardiovascular Monitoring Services

• Cardiovascular monitoring services are diagnostic medical procedures using in-person  and remote technology to assess cardiovascular rhythm (ECG) data.

• Holter monitors (93224-93227) include up to 48 hours of continuous recording.



Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use a Holter monitor. ICD-10-CM codes and/or ranges are provided below to help with your decision process.


ICD-10-CM Description             ICD-10-CM  Code/ Range

Abnormalities of breathing R06.00-R06.9

Abnormalities of heart beat R00.0-R00.9

Aneurysm of heart I25.3

Angina pectoris 120.0-120.9

Atrial fibrillation and flutter I48.0-I48.92

Bradycardia, unspecified R00.1

Cardiac arrest I46.2-I46.9

Cardiac murmurs and other cardiac sounds R01.0-R01.2

Chronic ischemic heart disease I25.10-I25.9

Dizziness and giddiness R42

Gangrene, not elsewhere classified I96

Old myocardial infarction I25.2

Other cardiac arrhythmias I49.0-I49.9

Pain in chest R07.1-R07.9

Paroxysmal tachycardia I47.0-I47.9

ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I21.0-I21.4

Subsequent ST elevation (STEMI) and  non-ST elevation (NSTEMI) myocardial

infarction I22.0-I22.9

Syncope and collapse R55


External Electrocardiographic Recording Services - CPT codes 93224, 93225, 93226, and 93227 Reported with Modifier 52

CPT codes 93224 – 93227 are reported for external electrocardiographic recording services up to 48 hours by continuous rhythm recording and storage. CPT coding guidelines for codes 93224 – 93227 specify that when there are less than 12 hours of continuous recording modifier 52 (Reduced Services) should be used.

When modifier 52 is appended to CPT code 93224, 93225, 93226, or 93227, Oxford does not apply the Time Span Codes Policy for reimbursement of these codes. Instead, Oxford applies the “Reduced Services Policy” which addresses reimbursement for codes appended with modifier 52.


Holter monitoring is a form of long-term ECG recording. It is a diagnostic procedure that provides a continuous record of electrical activity of a patient’s heart while the individual is engaged in ordinary activities, including sleep. Holter monitoring is used to detect abnormalities related to rhythm, rate, conduction and ischemia, which are not observed using a standard ECG.
Basic components of Holter monitoring systems are a sensing element, an appropriate recording of ECG information or significant variations in rate or arrhythmia, and a component for graphically recording ECG data or for visual or computer assisted analyses of recorded taped information.

Indications
  • Detecting transient episodes of cardiac dysrhythmia, permitting correlation of these episodes with cardiovascular symptoms.
  • Evaluation of the patient with symptoms suggestive of a cardiac dysrhythmia when another cause cannot be established.
  • Evaluation of arrhythmias in patients with documented coronary artery disease, including the assessment of the immediate postmyocardial infarction patient.
  • Monitoring the effectiveness of antiarrhythmic therapy.
  • Syncope and presyncope are covered indications for Holter monitoring and real-time monitoring.

Limitations
  • Holter monitoring and real-time monitoring are not covered for the detection of silent ischemia in patients without symptoms suggestive of ischemia. Routine screening in the absence of signs, symptoms, and complaints is not covered under Title XVIII of the Social Security Act, Section 1862(a)(7).
  • Holter monitoring and real-time monitoring are not covered for patients with incidental findings of conduction system defects absent a qualifying indication listed above.
  • Holter monitoring and real-time monitoring for vague symptoms such as dizziness are not covered in the absence of symptoms or signs that would suggest cardiac origin of the symptoms.

Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11X, 13X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
93224©
Ecg monit/reprt up to 48 hrs
93225©
Ecg monit/reprt up to 48 hrs
93226©
Ecg monit/reprt up to 48 hrs
93227©
Ecg monit/reprt up to 48 hrs


Coverage Indications, Limitations, and/or Medical Necessity

Long-Term ECG Monitoring is defined as a diagnostic procedure, which can provide continuous recording capabilities of ECG activities of the patient's heart while the patient is engaged in daily activities. These can include continuous, patient-demand or auto-detection devices. The purpose of these tests is to provide information about rhythm disturbances and waveform abnormalities and to note the frequency of their occurrence.

Cardiac Event Detection (CED) is a 30-day service for the purpose of documentation and diagnosis of paroxysmal or suspected arrhythmias. 

Holter Monitoring (24-hour ECG monitoring) is a study used to evaluate the patient's ambient heart rhythm during a full day's (24 Hours) cycle. It is a wearable EKG monitor that records the overall rhythm and significant arrhythmias. 

Medical Necessity:

The medical necessity indications listed in this policy must be present in order for these tests to be covered.

Indications for external 48-hour ECG recording include one or more of the following:

Symptoms:

Arrhythmias

Chest pain

Syncope (lightheadedness) or near syncope

Vertigo (dizziness)

Palpitations

Transient ischemic episodes

Dyspnea (shortness of breath)

Evaluation of the response to antiarrhythmic drug therapy.

Evaluation of myocardial infarction (MI) survivors with an ejection fraction of 40% or less.

Assessment of patients with coronary artery disease with active symptoms, to correlate chest pain with ST-segment changes.

Other acute and subacute forms of ischemic heart disease.

To detect arrhythmias post ablation procedures.

The use of 0295T, 0296T, 0297T and 0298T, external electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage, may be considered medically necessary in patients treated for reasons listed in the diagnosis list to monitor for asymptomatic episodes in order to evaluate treatment response. The use of external electrocardiographic event monitors for more than 48 hours up to 21 days that are either patient-activated or auto-activated may be considered medically necessary as a diagnostic alternative to Holter monitoring in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (i.e., palpitations, dizziness, presyncope, or syncope).

Long term 30-day monitoring: Telephonic Transmission of ECG involves 24 hour attended monitoring per 30 day period of time; no other EKG monitoring codes can be billed simultaneously with these codes.
Indications for performing a Telephonic Transmission:
Arrhythmias

Chest pain

Syncope (lightheadedness) or near syncope

Vertigo (dizziness)

Palpitations

Transient ischemic episodes

Dyspnea (shortness of breath)

To initiate, revise or discontinue arrhythmia drug therapy.

Evaluation of myocardial infarction (MI) survivors.

Evaluation of acute and subacute forms of ischemic heart disease.

Assessment of patients with coronary artery disease with active symptoms, to correlate chest pain with ST-segment changes.



Electrocardiograph Holter Monitoring Policy Status: Active  Effective: 12/01/2012

Please note: All policies are subject to the terms, conditions and limitations of the member’s plan or program

Description

Holter monitors are portable devices that capture 48 hours or more of continuous external electrocardiographic (ECG) recording and storage, and are used to detect atypical heart rhythms.

The services comprising Holter monitoring can be reported by using one Current Procedural Terminology (procedure ®) code for the global service, or they can be reported by using a combination of the professional and technical component codes for:

• recording of the ECG (which includes the hook-up and disconnection)

• scanning analysis with report

• physician review and interpretation

Policy

1. Non-hospital setting:

ECG Holter Monitoring is eligible for reimbursement when billed as a global service which encompasses both the technical and the professional components, or when a combination of the technical and the professional component services are reported. When a participating provider utilizes an outside non-par vendor for some or all of the technical components of this service, the participating provider is responsible for billing the global service (technical and professional components) and reimbursing the subcontracted vendor.

This will avoid increased member financial liability due to your use of an out-of-network provider as well as member abrasion.

 2. Hospital Setting:

Hospital-Based Physicians and private physicians are only eligible to be reimbursed for the professional component. The hospital may bill for the technical components.

Coding Holter Monitoring

93224----external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation

93225----recording (includes connection, recording, and disconnection)

93226----scanning analysis with report

93227----physician review and interpretation


ICD-10 CODE DESCRIPTION

I20.0 Unstable angina

I20.1 Angina pectoris with documented spasm

I20.8 Other forms of angina pectoris

I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery

I21.29 ST elevation (STEMI) myocardial infarction involving other sites

I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites

I24.0 Acute coronary thrombosis not resulting in myocardial infarction

I24.1 Dressler's syndrome

I24.8 Other forms of acute ischemic heart disease

I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm

I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris

I25.2 Old myocardial infarction

I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris

I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm

I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris

I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris

I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris

I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris

I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris

I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris

I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented 
spasm

I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris

I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina

I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm

I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris

I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina

I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm

I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris

I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris

I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris

I44.0 Atrioventricular block, first degree

I44.1 Atrioventricular block, second degree

I44.2 Atrioventricular block, complete

I44.39 Other atrioventricular block

I44.4 Left anterior fascicular block

I44.5 Left posterior fascicular block

I44.69 Other fascicular block

I44.7 Left bundle-branch block, unspecified

I45.0 Right fascicular block

I45.19 Other right bundle-branch block

I45.2 Bifascicular block

I45.3 Trifascicular block

I45.4 Nonspecific intraventricular block

I45.5 Other specified heart block

I45.6 Pre-excitation syndrome

I45.81 Long QT syndrome

I45.89 Other specified conduction disorders

I47.0 Re-entry ventricular arrhythmia

I47.1 Supraventricular tachycardia

I47.2 Ventricular tachycardia

I47.9 Paroxysmal tachycardia, unspecified

I48.0 Paroxysmal atrial fibrillation

I48.1 Persistent atrial fibrillation

I48.2 Chronic atrial fibrillation

I48.3 Typical atrial flutter

I48.4 Atypical atrial flutter

I48.91 Unspecified atrial fibrillation

I48.92 Unspecified atrial flutter

I49.01 Ventricular fibrillation

I49.02 Ventricular flutter

I49.1 Atrial premature depolarization

I49.2 Junctional premature depolarization

I49.3 Ventricular premature depolarization

I49.5 Sick sinus syndrome


I49.8 Other specified cardiac arrhythmias

R00.1 Bradycardia, unspecified

R00.2 Palpitations

R06.01 Orthopnea

R06.02 Shortness of breath

R06.09 Other forms of dyspnea

R06.2 Wheezing

R06.3 Periodic breathing

R06.4 Hyperventilation

R06.81 Apnea, not elsewhere classified

R06.82 Tachypnea, not elsewhere classified

R06.83 Snoring

R06.89 Other abnormalities of breathing

R07.2 Precordial pain

R07.82 Intercostal pain

R07.89 Other chest pain

R07.9 Chest pain, unspecified

R29.5 Transient paralysis

R40.4 Transient alteration of awareness

R42 Dizziness and giddiness

R55 Syncope and collapse

Z79.891 Long term (current) use of opiate analgesic

Z79.899 Other long term (current) drug therapy

ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 93224, 93225, 93226 and 93227:
Covered for:
345.00–345.01
Epilepsy and recurrent seizures
345.10–345.11
Epilepsy and recurrent seizures (generalized)
345.2–345.3
Epilepsy and recurrent seizures (mal status)
345.40–345.41
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures
345.50–345.51
Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures
345.60–345.61
Infantile spasms
345.70–345.71
Epilepsia partialis continua
345.80–345.81
Other forms of epilepsy and recurrent seizures
345.90–345.91
Epilepsy unspecified
410.00–410.02
Acute myocardial infarction
410.10–410.12
Acute myocardial infarction of other anterior wall
410.20–410.22
Acute myocardial infarction of inferolateral wall
410.30–410.32
Acute myocardial infarction of inferoposterior wall
410.40–410.42
Acute myocardial infarction of other inferior wall
410.50–410.52
Acute myocardial infarction of other lateral wall
410.60–410.62
True posterior wall infarction
410.70–410.72
Subendocardial infarction
410.80–410.82
Acute myocardial infarction of other specified sites
410.90–410.92
Acute myocardial infarction of unspecified site
411.0–411.1
Other acute and subacute forms of ischemic heart disease
411.81–411.89
Acute coronary occlusion without myocardial infarction
412
Old myocardial infarction
413.0–413.1
Angina pectoris
413.9
Other and unspecified angina pectoris
414.00–414.07
Other forms of chronic ischemic heart disease
414.10–414.12
Aneurysm and dissection of heart
414.19
Other aneurysm of heart
414.8–414.9
Other forms of chronic ischemic heart disease
422.0
Acute myocarditis in diseases classified elsewhere (Note: code underlying disease first.)
422.90–422.93
Other and unspecified acute myocarditis
422.99
Other myocarditis
424.0
Mitral valve disorders
425.0–425.5
Cardiomyopathy
426.0
Atrioventricular block complete
426.10–426.13
Atrioventricular block, other and unspecified
426.2–426.4
Conduction disorders
426.51–426.54
Bundle branch block, other and unspecified
426.7
Anomalous atrioventricular excitation
426.9
Conduction disorder, unspecified
427.0–427.2
Cardiac dysrhythmias
427.31–427.32
Atrial fibrillation and flutter
427.41–427.42
Ventricular fibrillation and flutter
427.5
Cardiac arrest
427.60–427.61
Premature beats
427.69
Other premature beats
427.81
Sinoatrial node dysfunction
427.89
Other specified cardiac dysrhythmias
427.9
Cardiac dysrhythmia unspecified
428.0–428.1
Heart failure
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure unspecified
429.0
Myocarditis, unspecified
429.4
Functional disturbances following cardiac surgery
429.83
Takotsubo syndrome
434.10–434.11
Cerebral embolism
435.8–435.9
Transient cerebral ischemia
674.50–674.54
Peripartum cardiomyopathy
780.2
Syncope and collapse
780.31–780.32
Convulsions
780.39
Other convulsions
780.4
Dizziness and giddiness
785.0–785.1
Symptoms involving cardiovascular system
786.00–786.09
Symptoms involving respiratory system and other chest symptoms
786.50–786.52
Chest pain
786.59
Other chest pain
794.30–794.31
Cardiovascular (abnormal)
794.39
Other nonspecific abnormal function study of cardiovascular system
996.01–996.04
Mechanical complication of cardiac device, implant and graft
996.09
Other mechanical complication of cardiac device implant and graft
996.72
Other complications due to other cardiac device implant and graft
V12.53
Personal history of sudden cardiac arrest
V45.01
Cardiac pacemaker in situ
V45.02
Automatic implantable cardiac defibrillator in situ
V45.09
Other specified cardiac device in situ
V58.69
Long-term (current) use of other medications
V67.51
Follow-up examination following completed treatment with high-risk medication not elsewhere classified
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
DESCRIPTION OF SERVICES

Cardiac arrhythmias are abnormal heart rhythms. Although some patients with arrhythmias may experience palpitations, weakness, dizziness or fainting, other patients may have no symptoms at all. Effective treatment requires an accurate diagnosis. This can be difficult since arrhythmias can occur infrequently and unpredictably and may be asymptomatic (ECRI, 2014). The type and duration of ambulatory electrocardiography (ECG) monitoring is dictated by the frequency of symptoms.

• Holter monitors are portable devices that record heart rhythms continuously for up to 48 hours. These devices are used to record events that occur at least once a day.

• Non-implantable cardiac event monitors are portable devices that record heart rhythms intermittently for up to 30 days.

These devices capture ECG data before, during and after the time of activation.

• Standard loop recorders have just a few minutes of memory. Newer, more sophisticated devices have extended memory features that can store up to several hours of ECG data.

Recording can be patient-activated when symptoms occur or automatically triggered based on a computer algorithm designed to detect arrhythmias. These devices are used to record infrequent or irregular events.
Documentation Requirements
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • A formal report for every study must be generated that indicates the reason(s) for the test and includes the electrocardiographic interpretation.
  • An appropriate medical evaluation of the patient prior to the test must be documented in the patient’s record by the referring physician. This should include a history and physical examination that is of sufficient scope and detail to support medical necessity for the test.
  • To verify the necessity and reasonableness of the test, the performing physician should, at minimum, document the diagnostic impression of the referring physician and indicate the patient’s relevant signs, symptoms or pertinent history in his records. The simple statement of certain non-specific test indications (such as chest pain or palpitations, etc.) is unacceptable medical necessity documentation.

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