Cardiac Device Monitoring

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Cardiac Device MonitoringCoding Update for
2009PresentersBruce L. Wilkoff MDDirector
of Cardiac Pacing and Tachyarrhythmia
DevicesCleveland ClinicLinda Gates-Striby
CCS-P, ACS-CA  Compliance Manager   The Care
Group, LLC Cathie BigaPresident/CEO
Cardiovascular Management of Illinois
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ACC/HRS/CMS Consensus

• Current CPT code selections for CIED Monitoring
• Do not reflect current practice and technology.
  
• Inadequate for reporting
• Professional
• Technical
• Need to modernize
• Current codes
• Code descriptions
• Provide for evolving technology

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CPT Code Revisions
Desired Outcomes
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Structure for 2009 Codes

• Programming CIED Evaluations
• Interrogation CIED Evaluations
• Remote
• In person
• Trans-telephonic Rhythm Strip Evaluations
• Peri-procedural Programming Device Evaluations
• Implantable Cardiac Monitors
• Implantable Loop Recorders
• Mobile Cardiovascular Telemetry

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Overview
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Programming Device Evaluations
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Programming Device Evaluation Definition

• All device functions, including the battery,
  programmable settings and lead(s) when present
  are Interrogated evaluated. Iterative
  adjustments provide information that permits the
  operator to assess and select the most
  appropriate final program parameters to provide
  for consistent delivery of the appropriate
  therapy and to verify the efficiency and function
  of the device.

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Lead Systems

• Device, single leadpacing sensing in one
  chamber of the heart (e.g., VVI system)
• Device, dual leadpacing sensing in two
  chambers of the heart (e.g., DDD system)
• Device, multiple leadpacing sensing in three
  or more chambers of the heart (e.g.,
  biventricular system)

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Peri Procedural Programming Evaluation
Definition

• The device system data are interrogated to
  evaluate the lead(s), sensor(s) and battery along
  with review of stored information including
  patient and system measurements. The device is
  programmed to settings appropriate for the
  surgery, procedure or test. A second evaluation
  and programming are performed after the surgery,
  procedure or test to provide settings appropriate
  to the post procedural situation.

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Interrogation Device EvaluationIn Person
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Interrogation Device Evaluation Remote
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Interrogation Device Evaluation
DefinitionRemote OR In Person

• Using an office, hospital or emergency room
  instrument, stored and measured information about
  the lead(s) when present, sensor(s) when present,
  battery and the implanted pulse generator
  function, as well as data collected about the
  patients heart rhythm and heart rate is
  retrieved. The retrieved information is evaluated
  to determine the current programming of the
  device and to evaluate certain aspects of the
  device function, such as battery voltage, lead
  impedance, tachycardia detection settings, and
  rhythm treatment settings.

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Trans Telephonic Rhythm Strip Evaluation
Definition

• Also called transtelephonic pacemaker monitoring.
  The service is an electrocardiographic rhythm
  strip transmitted over the telephone by the
  patient using a transmitter and recorded by a
  receiving location using a receiver/recorder. The
  electrocardiographic rhythm strip is recorded
  both with and without a magnet applied over the
  pacemaker. The rhythm strip is evaluated for
  heart rate and rhythm, atrial and ventricular
  capture (if observed) and atrial and ventricular
  sensing (if observed). Also the battery status is
  determined by measurement of the paced rate
  during the magnet applied electrocardiographic
  rhythm strip.

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Implantable Cardiovascular Monitor Definition

• Used to assist the physician in the management of
  non-rhythm related cardiac conditions such as
  heart failure. The device collects longitudinal
  physiologic cardiovascular data elements from one
  or more internal sensors and/or external sensors
  for patient assessment and management. The
  function of the ICM may be an additional function
  of an implantable cardiac device (CRT-D) or a
  function of a stand-alone device.

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Implantable Loop Recorder Definition

• An implantable device that continuously records
  the electrocardiographic rhythm triggered
  automatically by rapid and slow heart rates or by
  the patient during a symptomatic episode. The ILR
  function may be the only function of the device
  or it may be part of a pacemaker or ICD.

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Mobile Cardiovascular Telemetry

• A wearable device that continuously records the
  electrocardiographic rhythm from external
  electrodes. Segments of the ECG data are
  automatically (without patient intervention)
  transmitted to a remote surveillance location by
  cellular or landline telephone signal. There is
  continuous real time data analysis by
  preprogrammed algorithms in a device and attended
  surveillance of the transmitted rhythm segments
  by a surveillance center. The surveillance
  center technician reviews the data and notifies
  the physician depending upon the prescribed
  criteria.

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Action Plan For Implementation

• Successful implementation requires planning and
  multiple steps
• 2009 brings changes not only to the device codes
  but to echo and stress echo, as well as others
  (i.e. injections and infusion codes)

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Education and Awareness

• Identify your implementation team
• - include a physician representative
• - device clinic staff
• - holter/event monitoring representative
• - coders and billers
• - consider CHF clinic and scheduling staff

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Identify Your Services

• Are you performing or planning to perform remote
  checks?
• If providing remote services, are you performing
  the technical side as well?
• Do you have patients with devices that would
  qualify as an ICM? Is anyone using that data?
• Are you performing or planning to perform MCOT?

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Review The Billing Process

• How are charges being submitted now?
• How will you handle so many 90 and 30 day
  services?
• What changes will be needed for your billing
  forms/fee tickets?
• Are there EMR implications?
• Will you want to track the number of services
  actually rendered in a 90 day period?
• How will you ensure all billable services have
  been captured?

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Documentation Review

• Where do you keep your device check reports?
• Can you distinguish a remote service from an
  in-person interrogation?
• Review your reports for the key components of a
  programming evaluation versus an interrogation
  evaluation.
• Will you need to make any changes in your
  documentation?
• Are there implications to software that you may
  be using for device checks?

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Additional Factors To Consider

• Review supervision requirements
• Watch for CCI changes
• Watch for changes in local and National medical
  policies
• We know CMS is covering the services, but what
  about commercial payors?

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Areas To Watch

• Reprogramming is not the determining factor for
  choosing the correct code
• Interrogation codes same code for a single,
  dual and multi lead device
• Programming codes codes change for single, dual
  and multi lead
• Dont forget to bill for the technical side of
  remote services if you are performing that
  service
• How do we fit the new codes into existing medical
  policies?
• Watch for inappropriate denials chances are we
  understand the rules better than the payors

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Administrative Concerns

• Setting your fee
• - Consider implications of 30 or 90 day codes
• - Keep in mind CMS did not accept the full AMA
  recommended RVU on all codes
• - We cant tell you how to set your fee or what
  your fee should be, only issues to consider

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Contracted Rate Implications

• Identify your top commercial payors and evaluate
  for contract implications
• Do you have contracts that were negotiated per
  CPT code?
• Do you have contracts that locked in to a
  previous year of Medicare reimbursement?

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Budget Process

• Understand that the codes do not have a direct
  crosswalk
• Determine how you will conduct your financial
  analysis
• 2009 is a complicated year on its own how deep
  will you really need to go into the new device
  codes?
• 2009 echo codes are a bit easier to estimate

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Compensation Models

• Will your compensation model require that you
  track all services rendered?
• Example The physician doing the first read of
  a 90 day service will probably be your billing
  provider. Do you need to credit the physician
  who may read other services in that 90 day
  period?

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Additional Upcoming Presentations

• Heart Rhythm Society
• December 17, 2008
• January 12, 2008
• MedAxiom
• December 4, 2008

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2009 New Code Overview
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2009 New Code Overview
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2009 New Code Overview
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Thank You!

• If you should have any additional questions,
  please feel free to contact
• Brian Whitman or Rebecca Kelly at the American
  College of Cardiology
• 202-375-6000

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