A retrospective review of the medical records of 150 cardiac patients who had deactivated their implanted electronic cardiac devices (by request) revealed that both physicians and patients are not planning ahead or including their aspirations regarding the deactivation of devices in their advance directives. This is in spite of the fact that except one, all the patients analyzed had quite poor or terminal prognosis at the time the device was deactivated.
The investigation also showed that surrogates rather than the patients themselves had made half of all deactivation requests, and the requests were often made just days before the death of the patient. The author of the study opined that it is very important to encourage patients to execute advance directives with device-specific language so that they can ensure receiving care consistent with their preferences.
The other major findings of the review published in JAMA Journal are:
- Out of 150 devices, 135 devices were implantable cardioverter-defibrillators
- 79% of patients underwent deactivation of tachycardia therapies only
- 55% of deactivations were carried out by nurses while 15% was by industry-employed allied professionals
- Among 89 advance directives, just one specifically mentioned about the implanted device
- Median survival after deactivating the cardiac device was only two days
- The patients who made the deactivation decision themselves more commonly consulted a palliative-care practitioner
The two commentaries that accompanied this paper deal with the uneasiness felt by many physicians about end-of-life discussions and provide recommendations on how such kind of discussions could be broached. According to the authors of the commentaries, it is necessary to couple technological advancements with greater communication skills for providing quality care to cardiac patients. With an aging population and a corresponding increase in the use of cardiac devices, open communication is necessary between physicians, patients and their caregivers to ensure improved quality of the lives and deaths of terminally ill patients.
Cardiac device monitoring is an important service physicians provide for patients with implanted cardiac devices. Let us consider how a physician is to report cardiac device monitoring with different cardiac devices.
Reporting Cardiac Device Monitoring
When reporting cardiac device monitoring, the following codes are used.
IMPLANTABLE PACEMAKER
- 93288: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system
- 93279: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead pacemaker system
- 93280: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead pacemaker system
- 93281: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; multiple lead pacemaker system
- 93294: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional
- 93296: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
- 93293: Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional, up to 90 days
IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR
- 93289: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead implantable cardioverter-defibrillator system, including analysis of heart rhythm derived data elements
- 93282: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead implantable cardioverter-defibrillator system
- 93283: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; dual lead implantable cardioverter-defibrillator system
- 93284: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; multiple lead cardioverter-defibrillator system
- 93295: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional
- 93296: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
IMPLANTABLE CARDIOVASCULAR MONITOR
- 93290: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors
- 93297: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional
- 93299: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
IMPLANTABLE LOOP RECORDER
- 93285: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable loop recorder system
- 93291: Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable loop recorder system, including heart rhythm derived data analysis
- 93298: Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional
- 93299: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
Professional and Technical Components
Remote monitoring codes have distinct CPT codes for the professional (physician time and intensity in providing the service along with the activities before and after direct contact with the patient) and technical (resources used for performing the services) components. The Global CPT codes include the professional and technical components for in person codes. If both components of care are rendered in an office setting, there is no need to add modifier to the relevant code. Remote monitoring codes on the other hand, need 2 different CPT codes to be billed together – one code would represent the professional service and the other the technical service as for example CPT 93294 and 93296, 93295 and 93296, 93297 and 93299, and 93298 and 93299, when billing a global service.
It is required to add modifier –26 to the appropriate CPT code when only the professional component is performed. The -26 modifier need not be added if the code represents only the professional services signified by the CPT code description (e.g. CPT 93294, 93295, 93297, and 93298.) The modifier –TC must be appended to the appropriate CPT code when only the technical component is performed. The modifier –TC is not needed if the CPT code description represents only the technical support service as for example, CPT 93296 and 93299.
Medicare Directives
Now let us look at Medicare requirements in this regard.
- All remote interrogation services and transtelephonic pacemaker monitoring signified by codes 93296, 93299 and 93293 require general supervision of the technical component
- All in-person cardiac device interrogations require direct supervision of the technical component
General supervision signifies that the procedure is furnished under the physician’s overall direction and control. However, the physician’s presence is not required during the performance of the procedure. In general supervision, the training of non-physician personnel who actually carry out the diagnostic procedure and the maintenance of the necessary equipment/supplies rests with the physician.
For direct supervision, the physician must be present in the office suite and be always available to provide assistance and direction during the performance of the procedure. However, it does not mean that the physician should be actually present in the room when the procedure is performed.
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